Medical Versus Surgical Treatment of Pediatric Acute Mastoiditis: A Systematic Review

Abstract

Objective: There is no standard of care for treatment of pediatric acute mastoiditis (PAM). We systematically reviewed the English literature to evaluate the efficacy of PAM treatment options.

Methods: PubMed, Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from inception to January 2016, along with manual bibliography searches, for studies describing surgical or medical therapy. Two independent evaluators reviewed each abstract and article.

Results: We identified 310 articles, and 55 met inclusion criteria. Thirty-three evaluated surgical options and included 2,930 patients (mean age = 2.8 years) including those with myringotomy ± tube placement (n = 920); 140 needed additional surgery, drainage of subperisoteal abscess (SPA) (n = 142) ± myringotomy or tube placement, 29 patients needed additional surgery and mastoidectomy ± myringotomy or tube placement (n = 612), with 611 reporting resolution. Using a random effects model, the estimated success probability with 95% confidence intervals (CI) are myringotomy ± tube placement 94% (95% CI: 84.5%-97.8%), and drainage of subperiosteal abscess with concurrent myringotomy ± tube placement was 86.5% (95% CI: 66.4%-95.4%). Using a random effects model, mastoidectomy success was 99.7% (95% CI: 77.5%-100%). Nineteen studies evaluated medical therapy (n = 990 patients). The average cure rate was 71.7% (median = 70%; range, 26.3%-100%), and estimated success was 72.9% (95% CI: 60.5%-82.5%) by meta-analysis.

Conclusions: Myringotomy with or without tube placement and mastoidectomy have the highest cure rates for PAM. With SPA, incision and drainage with myringotomy with or without tube can be considered. Medical treatment cured nearly 72% of children. Ultimately, management should be based on surgeons' experience and judgment, patient characteristics, and severity of disease. Laryngoscope, 129:754-760, 2019.

Keywords: Antibiotics; mastoidectomy; mastoiditis; medical management; meta-analysis; outcomes; subperiosteal abscess; surgical management; systematic review.