Otomastoiditis por mycobacterium tuberculosis: un diagnóstico desafiante / Tuberculous otomastoiditis: a challenging diagnosis

RESUMEN La otomastoiditis tuberculosa es una presentación extremadamente rara de la forma extrapulmonar de la enfermedad y puede ser difícil llegar a su diagnóstico. Presentamos el caso de una paciente de 35 años con otomastoiditis tuberculosa bilateral acompañado de vértigo, hipoacusia mixta bilateral y paresia del nervio facial bilateral, como debut de una tuberculosis. Cultivos de Mycobacterium tuberculosis (MTB) y prueba de reacción en cadena de la polimerasa (PCR) de otorrea fueron inicialmente negativos. La tomografía computarizada de oídos y resonancia magnética mostraron cambios inflamatorios otomastoídeos bilaterales sin evidencia de erosión ósea ni extensión a partes blandas. Se realizó una mastoidotomía, las muestras del tejido obtenido evidenciaron osteomielitis crónica, bacterias ácido-alcohol resistentes y PCR positiva para MTB. La paciente recibió tratamiento con drogas antituberculosas durante 12 meses logrando una recuperación completa de la otalgia y vértigo, y mejoría parcial de audición y paresia facial. En resumen, los hallazgos clínicos e imagenológicos de la otomastoiditis tuberculosa son inespecíficos por lo cual se requiere de un alto índice de sospecha clínica para lograr el diagnóstico adecuado e iniciar el tratamiento de la infección subyacente.

ABSTRACT Tuberculous otomastoiditis is an extremely rare form of extrapulmonary disease that can be easily misdiagnosed. We hereby report the case of a previously healthy 35-yearold female with bilateral tuberculous otomastoiditis associated with vertigo, bilateral mixed hearing loss, and bilateral facial nerve palsy as the initial clinical presentation. Repeated Mycobacterium tuberculosis (MTB) culture and molecular testing of otorrhea aspirates were initially negative. High-resolution temporal bone computed tomography and magnetic resonance imaging showed partial opacification of the mastoid air cells without signs of bone erosion. A mastoidotomy was performed with mastoid tissue showing chronic osteomyelitis, positivity in acid-fast staining and MTB PCR. The patient was treated with a 12 month antituberculous treatment, with complete recovery of otalgia and vertigo, and improvement in hearing levels and facial nerve palsy. In summary, clinical and imaging findings for tuberculous otomastoiditis are non-specific, hence a high degree of suspicion is required in order to diagnose and promptly treat the underlying infection.

Aspectos clínicos y bacteriológicos de las mastoiditis agudas como complicación de otitis media aguda y crónica en pediatría, Experiencia en 10 años / Clinical and bacteriological features of acute mastoiditis as a complication of acute and chronic otitis media in pediatrics. A 10-years experience

Antecedentes. Cualquier paciente pediátrico o adulto que presente otitis media aguda (OMA) u otitis media crónica (OMC), particularmente colesteatomatosa, puede desarrollar complicaciones intratemporales y endocraneales, especialmente mastoiditis aguda (MA). Objetivo. Describir las características clínicas y bacteriología de los pacientes asistidos por MA como complicación de OMA y OMC. Lugar de aplicación: Servicio de Otorrinolaringología. Hospital de Pediatría Juan P. Garrahan. Diseño. Descriptivo, retrospectivo, transversal y observacional. Población. Pacientes con mastoiditis aguda por OMA y por OMC asistidos en el Servicio de ORL durante 10 años. Material y métodos. Revisión de historias clínicas de todos los pacientes tratados entre enero de 1999 y diciembre de 2008. Resultados. Se estudiaron 57 pacientes con MA, 40/57 por OMA y 17/57 por OMC. Hubo 40 niños hospitalizados con signos y síntomas de MA por OMA. Se diagnosticó complicación endocraneal en el 12,5% (5/40) de los casos. Los aislamientos bacterianos más frecuentes fueron Streptococcus pyogenes, Streptococcus pneumoniae, H. influenzae y Turicella otitidis. Se registraron 17 casos de niños hospitalizados con diagnóstico de MA y OMC. Ocurrieron complicaciones supurativas intracraneales en el 35,3% (6/17) de los casos. Los aislamientos bacterianos más frecuentes fueron las enterobacterias, P. aeruginosa y los gérmenes anaerobios. Conclusión. El diagnóstico de tipo y estadio de otitis media previa o coexistente a la complicación es fundamental para encarar el tratamiento antimicrobiano empírico inicial, sospechar complicaciones endocraneales asociadas y proponer procedimientos quirúrgicos menores, medianos o mayores oportunamente (AU)

Background. Any pediatric or adult patient presenting with acute otitis media (AOM) or chronic otitis media (COM), especially cholesteatomatous, may develop intratemporal and intracranial complications, mainly acute mastoiditis (AM). Objective. To describe the clinical and bacteriological features of patients seen for AM as a complication of AOM and COM. Setting: Department of Otolaryngology, Hospital de Pediatría Juan P. Garrahan. Design. A descriptive, retrospective, cross-sectional, observational study. Population. Patients with AM because of AOM and COM seen at the Department of Otolaryngology over a 10-year period. Material and methods. Review of the clinical charts of all patients treated between January 1999 and December 2008. Results. 57 Patients with AM, 40/57 due to AOM and 17/57 due to COM, were evaluated. Forty children were admitted to hospital with signs and symptoms of AOM-related AM. Intracranial complications were observed in 12.5% (5/40) of the patients. The most frequently isolated pathogens were Streptococcus pyogenes, Streptococcus pneumoniae, H. influenzae, and Turicella Otitidis. Seventeen children were hospitalized because of COM-related AM. Suppurative intracranial complications occurred in 35.3% (6/17) of the cases. The most frequently isolated pathogens were Enterobacteriaceae, P. aeruginosa, and anaerobic bacteria. Conclusion. The diagnosis of type and stage of otitis media prior to or coexisting with the complication is essential to address the initial empirical antimicrobial treatment, associated intracranial complications should be suspected and minor, intermediate, or major surgical procedures should be proposed at the appropriate time (AU)

Patología del hueso temporal en pediatría: hallazgos tomográficos característicos / Pediatric pathology of temporal bone: characteristic tomographic findings

El hueso temporal es asiento de patologías otológicas frecuentes en Pediatría. Objetivo. Realizar una evaluación estadística y la descripción de los hallazgos tomográficos característicos de la patología del hueso temporal en una población pediátrica. Materiales y Métodos. Trabajo retrospectivo, longitudinal y descriptivo de una revisión de 64 historias clínicas, realizadas entre enero de 2008 y abril de 2011 en el Hospital de Pediatría “Pedro Elizalde”. La clasificación de las patologías se dividió en: inflamatoria (infecciosa y no infecciosa), congénita, histiocitosis, infiltración tumoral y traumática.Resultados. Sexo masculino: 64%; rango etario: de 1 mes a 14 años (media: 6,1 años). Se encontró patología inflamatoria infecciosa en el 53% de los pacientes, patología inflamatoria no infecciosa en el 36%, congénita en el 4,6 %, histiocitosis en el 1,5%, infiltración tumoral en el 3% y traumática en el 1,5%. Predominó la patología infecciosa en los menores de 5 años (otomastoiditis: 43,6%). El colesteatoma constituyó la patología inflamatoria no infecciosa más común en el rango etario de 6 a 14 años (36%). No se presentaron lesiones neoplásicas propias, sino por infiltración tumoral (fibroangioma nasofaríngeo y metástasis de neuroblastoma). Conclusión. La otomastoiditis aguda y el colesteatoma constituyen la patología otológica más frecuente en Pediatría y requieren la realización de una Tomografía Computada (TC). En los casos revisados, el diagnóstico tomográfico coincidió con el clínico-quirúrgico y/o anatomopatológico...

Otomastoidite por lagochilascaris minor em criança: relato de caso / Minor lagochilascaris otomastoiditis in a child: case report

Introdução: A lagochilascariose é uma a zoonose emergente determinada pela presença do helminto Lagochilascaris minor em tecidos humanos. A infecção ocorre por meio da ingestão de larvas encistadas no tecido subcutâneo, na musculatura e vísceras de animais silvestres consumidos pelo homem de forma crua ou mal cozidos. A doença é rara, insidiosa, de caráter crônico, caracterizada pelo surgimento de lesões, principalmente na região do pescoço, mastoide, ouvido, rino e orofaringe. A gravidade, por vezes fatal, dependerá da localização do parasito. Objetivo: Descrever um caso de otomastoidite por L. minor em criança, atendida no Hospital das Clínicas da Universidade Federal de Goiás. Relato do Caso: Paciente 10 anos, sexo feminino, com queixa de otalgia intensa e otorreia purulenta à direita. À otoscopia, a orelha esquerda apresentava-se normal, enquanto na orelha direita havia edema retroauricular, pólipo no conduto auditivo externo e fístula com drenagem de secreção purulenta. A membrana timpânica estava íntegra. As etapas do atendimento foram descritas desde a consulta inicial até a recuperação da paciente. Comentários Finais: O clínico deve estar alerta para importância em se considerar o diagnóstico diferencial de tal afecção diante de indivíduos residentes em zonas rurais.

Introduction: The lagochilascariosis is an emerging zoonosis determined by the presence of helminth Lagochilascaris minor in human tissues. Infection occurs through ingestion of larvae encysted in the subcutaneous tissue, muscles and viscera of wild animals consumed by man so raw or undercooked. The disease is rare, insidious, chronic condition, characterized by the appearance of lesions, especially in the neck, mastoid, ear, nose and oropharynx. A serious, sometimes fatal, depend on the location of the parasite. Objective: To describe a case of otomastoiditis by L. minor in child, attended at the Hospital das Clinicas, Federal University of Goias. Case Report: Patient 10 years old female, complaining of otalgia and purulent otorrhea right. Otoscopy left ear was normal, while the right ear had retroauricular edema, polyps in the external ear canal and fistula with drainage of pus. The tympanic membrane was intact.The stages of treatment were described since the initial consultation to the recovery of the patient. Final Comments: The clinician should be alert to the importance in considering the differential diagnosis of this disease on individuals residing in rural areas.

Doenças inflamatórias da orelha média / Inflammatory diseases of the middle ear

OBJETIVO: Determinar as alterações tomográficas mais frequentes na doença inflamatória da orelha média e comparar os achados da tomografia computadorizada e da ressonância magnética com os dados otológicos e cirúrgicos. MATERIAL E MÉTODO: Foram comparados os resultados dos examesde imagem, clínico e cirúrgico de 95 pacientes (95 tomografias computadorizadas e uma ressonânciamagnética). RESULTADOS: Em 52 casos os resultados dos exames de imagem foram normais. Dos 43 pacientes com alterações radiológicas, a comparação com os achados dos exames de imagem, otolaringológico e histopatológico demonstrou: otomastoidite aguda em 2 (4,6%) pacientes, otomastoidite crônica unilateral em 9 (21,0%), otomastoidite crônica bilateral em 2 (4,6%), colesteatoma unilateral em 26 (60,5%) e colesteatoma bilateral em 4 (9,3%). CONCLUSÃO: A tomografia computadorizada foi capaz de definir as características das lesões e as complicações existentes na maioria dos casos e foi necessário o uso da ressonância magnética em um dos 43 pacientes com alterações radiológicas, para definir o tipo de material presente na orelha média. O conhecimento dos dados clínicos e do exame otológico permitiu a interpretação dos achados de imagem mais apropriada para cada caso.

OBJECTIVE: To determine the aspects and frequency of middle ear alterations at computed tomography and magnetic resonance imaging in patients with clinical suspicion for middle ear inflammatory disease. MATERIAL AND METHOD: Imaging examination resultsof 95 patients (95 computed tomography and 1 magnetic resonanceimaging) were compared with the results of otology, imaging and surgical findings. RESULTS: Fifty-two patients had normal imaging results. Forty-three patients had radiologic alterations compared to the physical, otology and hystopathologic exams: acute otomastoiditis in 2 patients (4.6%), unilateral chronic otomastoiditis in 9(21.0%), bilateral chronic otomastoiditis in 2 (4.6%), unilateral cholesteatoma in 26 (60.5%), and bilateral cholesteatoma in 4 (9.3%).CONCLUSION: Computed tomography was able to demonstrate the characteristics of the lesions and found complications in majority of the cases. Magnetic resonance imaging was used only in one patient to rule out scar and cholesteatoma. The knowledge of theclinical and otologic data enables the radiologist to elaborate a more appropriate interpretation of the imaging findings.

Mastoidite escamozigomática / Squamozygomatic mastoiditis

A mastoidite aguda que se apresenta de forma atípica, com edema temporal e/ou facial, é a chamada mastoidite escamozigomática. Existem poucos relatos sobre essa forma de mastoidite que ocorre devido à propagação do processo inflamatório à raiz da apófise zigomática, quando a pneumatização da mastóide atinge o zigoma ou a porção escamosa do osso temporal. O diagnostico é feito pela história, exame físico e tomografia computadorizada de mastóides. O tratamento é realizado com antibioticoterapia e cirurgia. OBJETIVO: Apresentar um caso de mastoidite escamozigomática e fazer revisão da literatura. PACIENTES E MÉTODOS: Relato de um caso avaliado em nosso hospital no ano de 2003 e revisão da literatura via internet; também foram usados livros de otorrinolaringologia de autores conhecidos. DISCUSSÃO: A mastoidite escamozigomática é uma das formas de apresentação atípica de mastoidite. Ocorre propagação do processo inflamatório até a apófise zigomática. A infecção atinge a escama do osso temporal e fistuliza-se entre esta e o músculo temporal, deslocando o pavilhão auricular para baixo e a podendo atingir face, olhos e pálpebra. O diagnóstico é feito através da historia, exame físico e tomografia computadorizada de mastóides. O tratamento é cirúrgico e associado à antibioticoterapia.

Acute atypical mastoiditis, with temporal and/or facial edema, is called squamozygomatic mastoiditis. There are only a few reports of this occurrence in the literature, which occurs because of an inflammatory process spread to the zygommatic apophysis, when mastoid pneumatization reaches the zygoma or the squamous portion of the temporal bone. Diagnosis is made based on clinical history, physical exam and mastoid CT scan. Treatment is carried out with antibiotic therapy and surgery. AIM: to present a case of squamozygomatic mastoiditis and review the literature. PATIENTS AND METHODS: report of a case treated in our hospital during the year of 2003 and literature review through the Internet, we also reviewed otolaryngology books from known authors. DISCUSSION: squamozygomatic mastoiditis is an atypical mastoiditis in which the inflammatory process spreads to the zygomatic apophysis. The infection reaches the temporal bone squamous portion and makes a fistula between this portion and the temporal muscle, shifting the pinna of the ear downwards and it may reach the face, eyes and eyelids. Diagnosis is carried out by clinical history, physical examination and mastoid CT Scan. Treatment is surgical, associated with antibiotic therapy.

Mastiodite masquée : à propos de deux observations

La mastoïdite masquée (MM) se définit comme un état inflammatoire latent de la muqueuse et de l'os mastoïdien avecun tympan normal. Elle est révélée par une complication généralement endocrânienne. Le traitement est une mastoïdectomie associée à une antibiothérapie intraveineuse.Nous rapportons deux observations de mastoïdites masquées dont le diagnostic a été évoqué par l'examen tomodensitométrique qui a rattaché les complications endocrâniennes à leur origine mastoïdienne. Le but de notre travail est de discuter les circonstances diagnostiques, les investigations paracliniques et le traitementdes mastoïdites masquées

Mastoiditis at Red Cross War Memorial Children's Hospital; Cape Town; 1999-2003

During the 5-year period 1999 - 2003; we treated 36 children with a clinical diagnosis of mastoiditis. Post-auricular tenderness; swelling or abscess was the presenting feature in all cases. Twenty of these children had acute mastoiditis; 12 had acute-onchronic mastoiditis and 4 had a post-auricular abscess and no signs of mastoiditis on mastoid exploration (pseudomastoiditis). No pathogenic organisms were cultured from 25of cases overall; but among those with positive culture Streptococcus pyogenes and Staphylococcus aureus were the commonest organisms in the acute mastoiditis group and Proteus mirabilis was the commonest in the acute-on-chronic group. In the acute mastoiditis group (20 patients) only 1 patient was successfully treated with antibiotics; the rest requiring cortical mastoidectomy. In the acute-on-chronic mastoiditis group (12 patients) 9 children had cholesteatoma and underwent an open cavity procedure and the other 3; who underwent cortical mastoidectomy; all had positive histology/culture for tuberculosis

Mastoidites: relato de estudo multicêntrico retrospectivo realizado em Israel entre os anos de 1984 e 1998 / Mastoiditis: report of a retrospective multicenter study conducted in Israel between the years 1984 and 1998

A otite média aguda é uma desordem comum à infância, com pico de incidência entre os 6 meses e os 2 anos de idade. Existe uma tendência da mastoidite aguda ocorrer em crianças que não tenham estória prévia de otite média. A introdução dos antibióticos mudou completamente a visão do tratamento da otite média, resultando em considerável declínio na incidência de mastoidite aguda e subsequente mastoidectomia, apesar disto, a doença continua sendo considerada como uma séria complicação da otite média...

Inflammatory diseases of the ear.

The inflammatory diseases of external and middle ear are one of the commonest conditions encountered by the pediatric physician. Inner ear inflammations are less common and need special and urgent attention. Special management in each case requires detailed history, examination, necessary investigations and appropriate referral to otolaryngologist when necessary. The article is aimed to help formulate a plan in managing the inflammatory conditions of ear. Otalgia constitutes the most prominent of the symptoms in external and middle ear inflammations whereas vertigo, tinnitus and sensory hearing loss form the symptom complex for inner ear infections. It is necessary to understand the basic pathophysiology of the inflammatory condition to be able to institute a targetted treatment. The audiometry impedance studies, microbiology of discharge and occasionally ABR and CT scan from the mainstay of investigative workup. The treatment is specific and based on the precise diagnosis. It often requires the help of an otolaryngologist. Decisions may have to be made with regards to the need for any surgical intervention particularly in acute otitis media, an external canal abscess or an acute mastoiditis. A case of chronic otitis media with facial palsy or vertigo (labyrinthitis being a possibility) needs urgent intervention.

Enoxacin en infecciones de oído medio y mastoides / Enoxacin in infections of middle ear and masthoids

Las infecciones crónicas de oído mastoides constituyen patologías de díficil tratamiento: en ellas encontramos infecciones mixtas y a veces resistentes a los antibioticos de uso oral. Enoxacin es una nueva quinolona de amplio espectro que ha demostrado eficacia contra gérmenes gram negativos incluída Pseudomonas aeruginosa. Nosotros estudiamos la eficacia de enoxacin oral en 26 pacientes con infecciones crónicas de oído y mastoides. Pueden según la necesidad asociarse a antibióticos antianaersbicos