Acute coalescent mastoiditis
is a rare
infection of the
bony process (the bone behind the ear). It is a severe infection which can spread to the brain causing
disability or death. It is usually caused by Streptococcal Pneumonia.
This bacteria is becoming more and more resistant to antibiotics. The
mechanism of penicillin resistance in this organism is by
producing a penicillin binding protein and not by producing penicillinase (an
enzyme which breaks down penicillin). Thus, this organism will also be
resistant to Amoxcillin/Clavulanate and Amoxcillin/Sulbactam.
bacterial resistance is transmitted on a plasmid between the bacteria.
A single plasmid can carry the genes for resistance to both the penicillin
Before the era of antibiotics, this disease was very common and the
treatment was with surgery. A
mastoidectomyoperation was routine and was
one of the most frequent operations at medical centers. With the
advent of antibiotics, the cases of
acute coalescent mastoiditis
However, when it occurred a complete
was performed. With the
newer stronger generation of antibiotics this disease was treated with a
( surgically creating a large
hole in the eardrum ) and IV antibiotics, reserving
for those cases with a
intracranial complications, vertigo, facial weakness or a sub-periosteal
abscess. Several articles have reported successful treatments
with the local drainage of the subperiosteal abscess, IV antibiotics and a
and NOT initially performing a
MRI (Magnetic Resonance Imaging) scans
may detect a fluid signal in the mastoid sinus on T2 studies. This
is often described as "mastoiditis" by the radiologist.
However, in the absence of pain, fever and an abnormal ear exam this
finding should not considered diagnostic of mastoiditis and is usually
considered a normal variant.
The case presented below is a child which developed
acute coalescent mastoiditis
with a sub-periosteal
abscess. Almost all cases develop from patient non-compliance or an
acute otitis media.
The child had been treated with multiple antibiotics including Augmentin ( Amoxcillin / Clavulanate
), none of which eradicated the infection.
Bacterial resistance was suspected and it was elected to perform complete
surgical drainage by performing a
Appearance of the Child. Note the protrusion of the
sub-periosteal abscess. The abscess at the time of surgery was
found to contain 6 cc of pus and had direct communication with the
air cells through a small bony dehiscence.
He cultured Streptococcal Pneumonia resistant to penicillin, trimethoprim/sulfamethoxazole, erythromycin and intermediate susceptible
of the child's ear showed an
acute otitis media. The
posterior-superior canal was not collapsed, as is sometimes seen in
CT-Scan was done which showed coalescence of the
the operation, the
was removed, exposing a large area of
coalescent air cells.
was performed. Most of the bone was
osteotic and soft, allowing removal with a curette. Other areas
had to be removed with a drill. A Penrose drain was placed and the
patient was started on IV Antibiotics, Vancomycin and Cefuroximine.
(The picture to the right is taken at 1/2 the magnification of the above
picture. The black outlined area represents the area of initial
bone removal shown in the picture above.)
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