The management of uncomplicated acute M includes the administration of parenteral antimicrobial therapy and myrinyotomy with or without the placement of tympanostomy tube (28). The main goal of therapy is to prevent spread of the infection to the central nervous system and to localize the infection. The antimicrobials used are vancomycin plus either ceftriaxone, or the combination of a penicillin plus a beta-lactamase inhibitor (i.e., ampicillin plus sulbactam). Oral therapy can substitute parenteral one if improvement occurred for a total of four weeks. Successful therapy markedly reduces the abscess size, the periosteal thickening, and tenderness decreases within 48 hours.
If no improvement occurs as may be evident by the patient's skin remaining red over a fluctuating abscess, or if fever and tenderness persist and do not improve within 48 hours, or if progression of the infection occurs manifested by the presence of increasing toxicity and extension of the disease process, surgical intervention and drainage may be necessary. Mastoidectomy is often required if cholesteatoma is present, or if suppurative complications occur (29). Mastoidectomy is rarely needed when adequate antibiotic therapy is administered early in the course of the disease. A recent study reported that mastoidectomy was performed in five of 21 (24%) patients (30). The surgical procedure that is generally used is simple mastoidectomy, accompanied by tympanostomy tube placement. Radical mastoidectomy is done only if no improvement occurs after simple mastoidectomy. The presence of osteitis is also an indication for surgery to prevent further intratemporal or intracranial complications.
The experience in the treatment of 72 children admitted to Children's Hospital of Pittsburgh between 1980 and 1995 with acute M complicating AOM showed that 54 (75%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy and 18 (25%) needed mastoidectomy for treatment of a subperiosteal or Bezold's abscess or cholesteatoma, or because of poor response to conservative treatment (13). This data illustrate that patients with acute M who had only periostitis generally respond to conservative therapy whereas those with acute mastoid osteitis usually require mastoidectomy.
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