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Algorithmic management of pediatric acute

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Algorithmic management of pediatric acute mastoiditis

Ioannis M. Psarommatis a,*, Charalampos Voudouris a, Konstantinos Douros b, Polyvios Giannakopoulos a,
Theodoros Bairamis a, Charalampos Carabinos a

ENT Department, P. & A. Kyriakou Childrens Hospital of Athens, Thivon & Levadias St, 11527-Goudi, Athens, Greece
3rd Department of Pediatrics, Athens University Medical School, University General Hospital Attikon, 1 Rimini St, 12464 Chaidari, Athens, Greece



Article history:
Received 11 December 2011
Received in revised form 11 February 2012
Accepted 13 February 2012
Available online xxx

Objective: Today, no uniformly accepted diagnostic and therapeutic criteria have been established for the
management of pediatric acute mastoiditis. The aim of this study is determine the efcacy and safety of
an algorithmic approach for treating pediatric acute mastoiditis.
Methods: The medical records of all children (n = 167) with a diagnosis of AM admitted in our center
during the period 20022010 were retrospectively studied. Data concerning medical history,
symptomatology, laboratory and imaging ndings, presence of complications, treatment methods
and nal outcomes were reviewed and analyzed. Parenteral antibiotics and myringotomy were applied
to all children on the day of admission. Initial surgical approach also included drainage or simple
mastoidectomy for subperiosteal abscesses and simple mastoidectomy for children suffering from
intracranial complications. Finally, simple mastoidectomy was performed as a second line treatment in
children showing poor response to the initial conservative approach.
Results: All children were cured after a mean hospitalization of 9.8 days. The rate of intracranial
complications at admission was 6.5% and the overall rate of the use of mastoidectomy 42%. Following the
presented treatment scheme in all cases, no child developed additional complications while in-hospital
and under treatment or after discharge.
Conclusions: Although simple mastoidectomy represents the most reliable and effective surgical method
to treat acute mastoiditis, a more conservative approach consisting of adequate parenteral antibiotic
coverage and myringotomy can be safely adopted for all children suffering from uncomplicated acute
mastoiditis. Non-responsive cases should undergo simple mastoidectomy within 35 days in order to
avoid further in-hospital acquired complications. Simple mastoidectomy should also be performed in
every case of unsuccessful subperiosteal abscess drainage or presence of intracranial complications.
2012 Elsevier Ireland Ltd. All rights reserved.

Acute mastoiditis

1. Introduction
Acute mastoiditis (AM) is the most common complication of
acute otitis media which mainly affects pediatric age with an
estimated incidence between 1.2 and 4.2/100,000 children/year
[1]. AM should be treated effectively and without delay because
severe intratemporal and potentially lethal intracranial complications can arise from further spreading of the disease.
Despite the extended bibliography relating to pediatric AM,
there are still many areas of controversy. Up to this point no
uniformly accepted diagnostic and therapeutic criteria have been
established. Concerning its management, simple mastoidectomy

Part of this work (years 20022009) was presented at 10th International

Congress of the E.S.P.O., 58 June 2010, Pamplona, Spain.
* Corresponding author at: 162 El. Venizelou Str, 13231-Petroupoli, Athens,
Greece. Tel.: +30 2105060696.
E-mail addresses: (I.M. Psarommatis), (K. Douros).

has historically represented the standard surgical treatment of

acute mastoiditis [2]. However, currently the rates of use of simple
mastoidectomy in treating pediatric AM show considerable
variations among reported series [3,4]. Besides, during the last
years, several centers have adopted a rather conservative
management for AM and its accompanying complications [58].
Even minor surgical interventions, like myringotomy, have been
questioned, since parenteral antibiotics are considered sufcient
for the treatment of AM [911]. Such a conservative approach may
be successful for a considerable proportion of the cases but may
not be adequately safe for all patients. Development of intratemporal and life-threatening intracranial complications or deterioration of pre-existing ones has been reported in children under
treatment that were suffering from AM [1215].
Although every case of AM may have its specic needs, it
becomes obvious that some basic directions must be set so as to
maximize treatment safety. In our institution a tertiary care
pediatric center a considerable experience on the management of
AM has been gathered during the last decades. The aim of this

0165-5876/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
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study is to evaluate the effectiveness and safety of the management of pediatric AM we employ in our department for more than
15 years. An attempt is also made to develop an algorithmic
approach in order to formalize the treatment of this disorder.
2. Patients and methods
The medical records of all children (n = 167) admitted to our
department with the diagnosis of AM between January 1st 2002
and December 31st 2010 were retrospectively reviewed. An
Institutional Scientic Board approved the review of the medical
charts of children admitted to our center with the diagnosis of
acute mastoiditis for the period of the study.
Data concerning childrens age, gender, history of pre-admission middle ear infections, clinical signs, treatment before and after
admission, surgical, bacteriological and radiological ndings and
the nal outcome were manually collected and analyzed. Exclusion
criteria included the presence of chronic otitis media with
cholesteatoma, otitis externa and any non-infectious etiology of
The diagnosis of AM was based on clinical signs and symptoms
and the criteria applied were recent history/symptoms/signs of
acute otitis media accompanied by retroauricular inammatory
signs (erythema/swelling/pain) and/or antero-inferior protrusion
of the auricle.
Diagnostic imaging, in the form of computed tomography
scan (CT) and/or magnetic resonance imaging (MRI) and/or
magnetic resonance venography (MRV), was performed only in
children with suspected intracranial complications, in recurrent
AMs and in non-typical presentations of AM, when diagnosis was
in doubt.
All children were managed with intravenous (IV) antibiotics
and wide-eld myringotomy with or without ventilating tube
placement within the rst day of hospitalization. Myringotomy
was also performed in cases presented with otorrhea at admission.
Depending on the presence of further intratemporal or intracranial
complications, initial surgical approach also included subperiosteal abscess drainage by incision or aspiration and simple
mastoidectomy. Selecting between abscess drainage and mastoidectomy in children suffering from mastoid subperiosteal abscess
was at the discretion of the attendant ENT surgeon, since both
approaches were used and still are during the years of this
study. However, the presence of an otogenic epidural and perisinus
abscess or lateral sinus thrombosis was considered an indication
for mastoidectomy in this series.
Blood tests, including white blood cell count (WBC) and
differential, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), were performed in all cases. Pus specimens were
obtained from all middle ears during myringotomy and from most
mastoid cavities during mastoidectomy and sent for culture/
All children were closely followed daily while the decisive reevaluation about the effectiveness of the applied therapeutic
measures was taking place 23 days after admission. Initial
management was considered as successful or not on the basis of
both clinical and laboratory criteria: progressive restoration of
auricular displacement, regression of retroauricular local signs,
partial or complete recovery of the laboratory values of inammatory markers and absence of fever. Cases with persistent clinical
and/or laboratory ndings of AM required further surgical
intervention. Persisting otorrhea for 26 days after myringotomy
and initiation of antibiotic therapy was not considered a denite
criterion for mastoidectomy if the rest of the clinical and laboratory
ndings had been improving or had returned to normal.
Nonetheless, long-lasting otorrhea (7 days) was considered a
positive criterion for performing mastoidectomy.

2.1. Statistical analysis

Time to discharge was depicted with a KaplanMeier plot. We
used Cox proportional hazards models and tried to identify
independent factors (age, sex, nonspecic inammatory parameters, such as WBC, CRP, and ESR on admission, and kind of isolated
bacteria) associated with time to discharge, since the latter may be
considered an indirect marker of disease severity.
3. Results
3.1. Epidemiology clinical presentation
From the total of 167 children, 5 children (3%) with
cholesteatoma and 4 children (2.5%) suffering from non-infectious
pathology (two cases of hystiocytosis X and two with acute
leukemia) were excluded from the review. Two children with otitis
externa, who initially were misdiagnosed as suffering from AM and
one cochlear implant recipient, were also excluded from the study.
The remaining 155 children consisted of 106 male and 49 female
(ratio 2.2:1, p = 0.001) with a mean age of 36.7 months (range 2
130 months, median 30 months). Yearly and seasonal distribution
of cases is shown in Fig. 1.
A complete personal history was available for 126 children and
the following information was obtained. Positive anamnesis for a
recent episode of AOM prior to AM was present in 73% of cases. The
mean duration of AOM symptoms before admission was 6.1 days
(range 117 days) and 68% of children had been treated for AOM
with oral antibiotics in an outpatient basis. The most frequently
prescribed oral antibiotics were low and high dose amoxicillin (24/
126), amoxicillin/clavulanate (17/126), 2nd generation cephalosporins (35/126) and clarithromycin (16/126). The average time
from the onset of AM until admission was 1 days (ranging from a
couple of hours to ve days).

Fig. 1. Annual (above) and seasonal (bellow) distribution of cases (n = 155). No

signicant change in the incidence during the study years has been noted.
Expectedly, monthly distribution shows a signicantly lower incidence during the
summer season, from June to September (p = 0.0034).

Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042

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and Staphylococcus aureus (5.2%). Mixed infections were found in 8

cases while no microorganisms were isolated from 20 specimens
Modication of the initial empiric antibiotic regimen was
deemed to be necessary in four cases due to in vitro bacterial
resistance revealed in the sensitivity tests.
All children were given oral antibiotics for another 710 days
after discharge. Children with intracranial complications received
15 days of oral antibiotic therapy.
Anticoagulation therapy was given in 2 (out of 4) cases of
sigmoid sinus thrombosis.
3.3. Surgical treatment

Fig. 2. Presenting symptoms and signs of 155 patients with acute mastoiditis.

Presenting symptoms and signs for the whole population are

shown in Fig. 2. All children had some evidence of post-auricular
inammation (redness and/or swelling and/or tenderness) and
most of them presented with auricular protrusion. Twenty three
cases showed an active ipsilateral otorrhea at presentation.
Fourteen children were presented with neurologic symptoms
suggesting CNS involvement and 4 with facial nerve palsy. The
average value for WBC, CRP and ESR on admission was 18,350/ml
(range 490035,400), 103 mg/dl (range 3308) and 86.9 mm/h
(range 10152), respectively.
Computed tomography scan was performed in 18, MRI in 7, and
CT plus MRI/MRV in 5 children. Imaging studies revealed 9 children
with intracranial complications, three of whom showed multifocal
intracranial lesions. Epidural abscess was revealed in 3, brain
abscess in 1 and sigmoid sinus thrombosis in 2 children. Cases with
multiple intracranial complications involved brain abscess plus
epidural abscess (n = 1), brain abscess plus perisinus abscess/
sigmoid sinus thrombosis (n = 1) and epidural abscess plus
sigmoid sinus thrombosis (n = 1, Fig. 3). Additionally, in one child
who had not been subjected to any imaging evaluation, an epidural
abscess was incidentally disclosed during simple mastoidectomy.
Intratemporal complications included 34 subperiosteal abscesses
(one of them was associated with epidural abscess) and 4 cases
with facial nerve paralysis.

Surgical treatment involved wide-eld myringotomy (inferior

posterior quadrat of the tympanic membrane) in all children,
including those presented with otorrhea, on the day of admission.
Ventilating tubes were inserted in 23 cases.
Initial surgical treatment in children with SA also included
simple mastoidectomy (n = 12) or abscess drainage (n = 21), using
incision or aspiration. From the latter subgroup, 12 children were
cured without any supplementary treatment while 9 required
mastoidectomy in the end (Fig. 4). Bony erosion responsible for
abscess formation was observed in most children during mastoidectomy (19 out of 22).
Most cases (9/10) suffering from an intracranial complication
were subjected to myringotomy and simple mastoidectomy on the
day of admission, through which epidural and perisinus pus
collections were accessed and drained. Only in one case with
severe CNS involvement was the initial surgical approach delayed
and performed on the 3rd in-hospital day. Sigmoid sinus was
completely uncovered in all (n = 4) children with sigmoid sinus
pathology and punctured in 3 cases. The presence of a neurosurgical team was requested in seven cases with intracranial
complications. However, neurosurgical intervention was not
necessary except in the cases of brain abscesses (n = 3).
Finally, simple mastoidectomy was performed in 34 cases of
uncomplicated AM who showed a poor response to initial
approach. This second surgical session took place between 3rd
and 5th day of hospitalization.
Overall mastoidectomy rate for the whole population (n = 155)
reached 42% while mastoidectomy rate for cases of uncomplicated
AM was 30.3%. No child included in this study was subjected to
revision simple mastoidectomy or radical/modied radical mastoidectomy.
3.4. Final outcomes

3.2. Medical treatment microbiology

Empiric intravenous antibiotics were initiated in all patients
shortly after admission. One hundred forty nine children received a
combination of antibiotics and only 6 cases were treated with
monotherapy. Combination therapy consisted of a third generation
cephalosporin (cefotaxime or ceftriaxone) and clindamycin. The
3rd generation cephalosporin was replaced by aztreonam in three
penicillin allergic children and the combination amoxicillin/
clavulanate plus clindamycin was used in two children. Brain
abscesses were initially treated with ceftriaxone plus vancomycin
plus metronidazole and steroids. Monotherapy included amoxicillin/clavulanate (n = 3), ampicillin/sulbactam (n = 2) and 2nd
generation cephalosporin (n = 1).
Antipyretics and analgesics were given on an individual basis.
The most common bacteria recovered from pus specimens
collected during myringotomy were Streptococcus pneumoniae
(40.6%), Staphylococcus coagulase negative (16.1%), Streptococcus
pyogenes (10.3%), Haemophilus inuenzae (9%), anaerobes (5.8%)

All children were cured and discharged after an average

hospitalization of 9.8 days (range 429 days, median 9 days).
A detailed illustration of hospital length of stay is depicted in
the KaplanMeier plot of estimated time to discharge (Fig. 5). None
of the examined variables (age, sex, WBC, CRP, and ESR on
admission, and kind of isolated bacteria) were predictive of the
time of hospitalization.
Except for those present on admission, no additional intracranial or intratemporal complications related to further spread of the
disease developed in this series during hospitalization. Likewise,
after a regular postoperative follow-up of all children for at least 5
months, no long-term intratemporal or intracranial complications,
sequelae or cases of masked mastoiditis were noted. The
observed small number of in-hospital acquired complications
were directly related to mastoidectomy and consisted of three
minor and one moderate surgical trauma infections and two
postoperative facial nerve palsies (6/65 or 9.2%). All of them were
managed conservatively with success.

Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042

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Fig. 3. Large bi-lobed epidural abscess (A, hollow arrow), pushing the ipsilateral sigmoid infero-medially (A, white long arrow) on brain contrast-MRI at presentation. The
enhanced and thickened overlying dura can also be visualized (A, white short arrow). At the same time, on MR phlebography complete occlusion of right sigmoid sinus can be
seen (B, double arrow). On pre-discharge follow-up imaging study, 20 days after simple mastoidectomy, hyperintense (inammatory) material is still lling the right mastoid
cavity (C, arrow) while partial recanalization of the right sigmoid can be observed (D, double arrow).

It is noteworthy that no child showed a temporary improvement 35 days after the initial therapeutic approach and a reworsening thereafter.
Five children suffered a second episode of uncomplicated AM
within 816 months after the rst episode, showing an asymptomatic in-between period. Three of them belonged to initially
mastoidectomized patients. All ve recurrences were further
managed following the same protocol. All cases of lateral sinus
thrombosis displayed evidence of complete recanalization on
follow-up magnetic resonance venography.
None of our patients was managed on an outpatient basis. There
were no deaths in this series.
4. Discussion
Depending on the presentation, extent of the disease, presence
of further complications and surgeons personal experience and
attitude, the management of pediatric AM may greatly vary among

different pediatric centers. One of the most characteristic

differences represents the contradictory rates of the use of
mastoidectomy for the treatment of AM, which uctuate between
9% and 88% [3,4,16]. Currently, many researchers seem to adopt a
conservative approach to pediatric mastoiditis which consists of
antibiotics alone or antibiotics plus myringotomy when a poor
response to antibiotics is observed [5,6,811].
It is true that many patients suffering from uncomplicated AM
will respond well to a purely conservative approach (antibiotics
only) but, unfortunately, we are still unable to reliably anticipate
which cases will show a poor response. Furthermore, we cannot
predict which cases will develop fatal intracranial complications.
The latter may vary greatly between 1 and 72.7% of AM cases and
they are usually present on admission but some of them may be
developed during hospitalization, while the patients are under
treatment [8,1120]. In a recent large multicenter study the
complication rate of AM on admission was 22%, among which 7.2%
intracranial [12]. In the same study, an alarming rate of in-hospital

Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042

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Fig. 4. Graphic representation of the patients/methods/results of the study. AM,

acute mastoiditis; CI, cochlear implant; VT, ventilating tubes; IV, intravenous; SA,
subperiosteal abscess (*children with intracranial complications had a longer

developed intracranial and intratemporal complications (8.5%) has

been reported. Logically, the use of more effective and reliable
methods of treatment should be sought.
This series differs from several reported ones in that no
complications related to further extent of the disease after
initiation of the in-hospital treatment have been observed within
an extended time period (9 years). Additionally, a close and long
term postoperative follow-up failed to identify cases with longterm sequelae or masked mastoiditis. These reassuring ndings
have driven us to conclude that the applied therapeutic measures
were toward the right direction, safe and effective. A straightforward algorithmic approach was followed in every case, whose
main steps can be summarized as follows: all children underwent
at least one surgical procedure for pus pressure relief and received
a combination of parenteral antibiotics on the day of admission. In
the case of good clinical and laboratory response after 23 days, no
further surgical treatment was applied and the child was
discharged when he/she was completely cured, usually in 810
days. Uncomplicated mastoidites and drained mastoid abscesses
with poor response to initial approach were further subjected to
simple mastoidectomy within 35 days after admission. Clinical
suspicion of an intracranial complication was always followed by

Fig. 5. KaplanMeier plot of estimated time to discharge for the population of the

proper imaging studies and, when positive, myringotomy plus

simple mastoidectomy in clinically and neurologically stable
children were applied (Fig. 6).
It is the authors belief that initial surgical approach to pediatric
AM plays a vital role in the nal outcomes. In this series the rst
surgical step consisted of myringotomy alone for the cases of
uncomplicated AM (in 112/155 children or 72.3%), myringotomy
plus simple mastoidectomy or abscess drainage for mastoid
subperiosteal abscesses (in 33/155 children or 21.3%) and
myringotomy plus simple mastoidectomy for AM associated with
extradural or lateral sinus/perisinus pathology (in 10/155 children
or 6.4%). Although a minor surgical intervention, early myringotomy seems to represent a key therapeutic action, which helps in
preventing further major operations or complications. Seventy
percent of our children (78/112) who were subjected to
myringotomy only were cured without additional surgical
measures. We found myringotomy useful even in children with
otorrhea at the time of presentation. In these cases a wider opening
of the tympanic membrane would offer better drainage, pus
sampling and a thorough ear assessment for excluding other
pathologies. Ventilation tubes were inserted in cases where a
positive previous history of middle ear problems was present.
Repeat myringotomies or abscess drainages were not employed
in this study. Instead, failure of the initial surgical approach forced us
to make use of simple mastoidectomy as the standard method of
treating AM within 35 days. In this way our patients remained
exposed to an inadequately controlled severe infection only for a
short time period and under the safeguard of broad spectrum
antibiotics. Whenever used, simple mastoidectomy proved an
extremely effective method for treating AM and its complications,
yielding the maximum success rate. In our series, none of the cases
required a revision simple mastoidectomy. Additionally, no need for
converting it to a radical/modied radical mastoidectomy was
noted, even in cases with contracted and sclerotic mastoid bones.
Subperiosteal, epidural and perisinus abscesses can also be safely
drained through this approach. No major complications related to
simple mastoidectomy have been noted in our population while the
few minor complications were treated conservatively.
The choice of the antibiotics to treat pediatric AM might
represent another reason for the presented favorable clinical
outcomes. Although effective in most cases, monotherapy always
leaves open some possibility of microbial growth while the
patients remain exposed to the toxicity of an infective
microorganism. Practically all children in our series (149/155
or 96.2%) received a combination of IV antibiotics a few hours
after admission which, theoretically, almost totally covered the
whole spectrum of microorganisms known to be involved in AM.
To our experience and based on the current level of knowledge
on the subject, combined antibiotic therapy (cefotaxime or
ceftriaxone + clindamycin) is a safer option for the patients than
monotherapy, without necessarily having more adverse effects
or a higher cost.
Finally, the duration of hospitalization may also play an
important role, affecting the nal outcomes. In some pediatric
centers a very short duration of hospitalization has been employed,
ranging between 1 or 2 and >15 days [5,7,15,21,22]. The optimal inhospital therapy for the disease has not yet been specied. However,
in our opinion an extremely short hospitalization (1 or 2 days) seems
inadequate for a safe management of the disease. This is particularly
true in cases of young infants suffering from complicated AM and
subjected to mastoidectomy. Furthermore, one can hardly make a
reliable prognosis for the progression of the disease after only 1 day
of treatment, because no sufcient time for substantial change of the
presenting symptomatology is offered, even if the proper initial
therapeutic approach has been used. For these reasons we never
used such a short duration of hospitalization on our patients. The

Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042

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In our population we found that simple mastoidectomy is the

most reliable and effective surgical option for AM with/without
associated complications. However, a more conservative approach
consisting of adequate parenteral antibiotic coverage and myringotomy could be safely adopted for all children suffering from
uncomplicated AM. A similar initial treatment option has also been
suggested by other researchers [18,23,24]. Non-responsive cases
should undergo a simple mastoidectomy within 35 days in order
to avoid further in-hospital acquired complications. Simple
mastoidectomy should also be performed in every case of
unsuccessful subperiosteal abscess drainage or presence of
intracranial complications.
Conict of interest
The authors declare that they have no conict of interest.

Fig. 6. Recommended algorithmic management to pediatric acute mastoiditis.

Notes: (1) with/without ventilating tubes; (2) in clinically and neurologically stable
children; (3) using clinical and laboratory criteria; (4) children with intracranial
complications may need longer in-hospital stay.

mean duration of hospitalization for the whole population of this

study was 9.8 days, which is higher than that reported by many other
researchers. It is our standard practice to discharge the children only
after a clean, non-inamed postauricular surgical trauma and a dry
and translucent tympanic membrane is restored. Adherence to such
a practice may possibly lengthen the hospital stay of the patients but
it may also protect them from some unpleasant complications. Only
3 cases who presented with the clinical picture of AM with periostitis
had 4 days of hospital stay, while a hospitalization of 14 days was
necessary in AMs associated with intracranial complication.
In acute infections, the nonspecic inammatory parameters
measure the severity of the acute phase reaction and reect tissue
damage caused by microbes. Nevertheless, we failed to show that
WBC, CRP, or ESR on admission are related to the length of hospital
stay. This may happen because length of stay is related mainly to
the spread of the disease and especially to the intracranial or
intratemporal complications and not to the severity of inammation per se. The kind of isolated bacteria was also not associated
with the length of stay, probably because all bacteria were
sensitive to the administered IV antibiotics.
Overall, most children of the study (n = 78 + 12 = 90 or 58%,
Fig. 4) were successfully treated by applying a conservative initial
approach, consisting of antibiotics plus myringotomy or abscess
drainage while in the remaining 42% a more aggressive surgical
treatment, in the form of simple mastoidectomy, was performed.
The relatively high rate of simple mastoidectomies probably
reects our efforts toward the direction of safety rather than other
statistical results. Using the presented algorithmic approach, both
treatment schemes (conservative or aggressive) were found to be
maximally safe, given that no mortality, in-hospital developed
morbidity and long-term sequelae were noted in this series.
5. Conclusions
The question of how much conservative is safe? in the
treatment of pediatric AM must be answered with randomized
prospective clinical studies. Till then, the less risky management
must be applied because the development of its life-threatening
complications should not be an option.

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Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042