So we arrive at another Wednesday wrap up. We had a really good line up that included the below:
|
Time:
|
Speaker:
|
Lecture:
|
| 8-8:50 | Basile | Peds Case Conference: ITP |
| 9 -9:50 | Krinsky | Peds Oral/Dental |
| 10 -10:50 | Kong | Peds Case Conference: Mastoiditis |
| 11 -11:50 | Dr. Khan | Pediatric Eye Emergencies |
There are multiple topics to discuss.
I think one of the most exciting topics to discuss is one of the topics that came up with Dr. Kong’s Lecture on Mastoiditis.
– Should Pediatric patient get CT scans for mastoiditis?
The discussion came up that most consult services and inpatient teams will request CT before admission or do the CT once admitted. So is there literature out there that either shows that patient do not need CT scans or that when they are done they do not offer management changes. So that is where the literature search begins.
In the American Journal of Otolaryngology 2010 Tamir et al. published Shifting trends: mastoiditis from a surgical to a medical disease.
In this paper they looked at pediatric patients over a three year period that had mastoiditis and were treated conservatively with IV antibiotics and myringotomy. They did, if necessary, also receive subperiosteal abscess incision and drainage.
During the 3 year period they looked at 51 pediatric patients who came in with mastoiditis. Two patient did receive CT upon admission. The other 49 were admitted and treated conservatively with IV antibiotics and myringotomy. 4 of the remaining 49 patient received CT scans while inpatient due to continued fever or lack of improvement. The CT scans were negative for intra-cranial process and the current management was continued.
I think this paper is a good paper that shows that the initial management for these patient should be conservative.
Tamir et al. had a similar paper published in 2009 Acute mastoiditis in children: is computed tomography always necessary? Which looks at the exact question we are looking at. This paper used the same data and showed that 92% of the pediatric patients did not receive CT and were treated conservatively with no complications.
A systematic review was done on mastoiditis in the pediatric population looking for set rules for the diagnostic criteria for mastoiditis in Otology & Neurotology 2008 van den Aardweg et al published A systematic review of diagnostic criteria for acute mastoiditis in children. They did an exhaustive search in PubMed, Embase, and the Cochrane Library. They came up with 65 studies that met their criteria. Only 26 mentioned criteria for diagnosis. The most common mentioned were all physical exam signs which included postauricular swelling, erythema, tenderness, and protrusion of the auricle. They did mention that 68% of pediatric patient received a CT scan but did not mention it as a criteria. Their conclusion was that there is not a good criteria list for diagnosis but it does not seem that anyone thinks that CT is mandatory or absolutely indicated.
Any thoughts? Do you think this is something that is feasible in the era of defensive medicine? Can we keep the inpatient teams from doing it? I want to hear your thoughts.
mritchie
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From looking over the papers it seems reasonable to not emergently do a CT scan on these patients. The patients in the studies with severe complications present very sick. Across the board it is small sample sizes due to being a rare condition so we should still be careful. I find it interesting that this is ENT literature and they’re always the ones who need the CT scan.
In the first two studies there are a large proportion of patients who were on abx already. Wonder if incomplete use of abx courses producing more virulent bacteria is a cause for some cases. Another reason to not give abx for AOM.
Obviously the decision is going to be made on a case by case basis, however, it seems reasonable in the absence of any red flags such as toxicity or focal deficit to make the diagnosis clinically and initiate treatment with IV abx and admit. The decision to CT scan in most cases is going to fall on the ENT docs and I’m sure some will CT everyone and some may be more discerning. Ultimately if ENT wants the CT it’s going to happen, so the best we can do is advocate for our patient and make them think twice as to if the scan is really necessary.