Management of complications of acute otomastoiditis in solid organ transplant patients.
Immunocompromised states, whether inherited or acquired, often times lead to infectious complications. The congenital and acquired syndromes that cause immune system dysfunction result in a variety of clinical manifestations depending on the exact cell line involved. (1) These clinical manifestations include both opportunistic infections as well as advanced, aggressive presentations of diseases common in the general population.
Organ transplant recipients are a significant patient population in which the infectious complications resulting from immunosuppression are encountered. Although neoplastic processes also occur, infection plays a considerable role in the mortality and morbidity in this population. (2) A significant portion of these infections arise in the head and neck, and timely recognition and treatment are important to preventing progression of disease. (3) More specifically, otomastoiditis, when occurring in immunosuppressed patients, has the potential to progress to serious, life-threatening intracranial complications including meningitis, intracranial abscess, and lateral sinus thrombosis. (5) It is the goal of this paper to demonstrate the importance of recognizing otomastoiditis, understanding its etiology, and quickly treating the disease to manage and prevent the advanced stages of infection in solid organ transplant patients.
A 63 year-old man presented in transfer to the Transplant Intensive Care Unit, three years after cadaveric renal transplant, with otorrhea and altered mental status. His family reported an upper respiratory infection and acute otitis media, treated initially at outside institution with PO antibiotics followed by tympanostomy tube placement with concurrent ototopical antibiotic drops when the infection failed to resolve. He continued to experience otorrhea and fever the day after the tympanostomy tube was placed despite these interventions, and subsequently his family brought him to an outside Emergency Department when his mental status deteriorated to a point where meaningful communication was not possible. His neurologic condition continued to deteriorate and ultimately intubation was required for airway protection.
He was admitted at the outside hospital, and IV antibiotics were begun. When no improvement was noted in 12 hours following broad-spectrum IV and ototopical antibiotic administration, he was transferred to the transplant surgery service at our institution. He rapidly progressed to meningitis, with sigmoid sinus thrombosis and sepsis, within 24 hours of arrival at the Transplant Intensive Care Unit, and high-resolution CT scan of the temporal bone was undertaken (Figure 1). Given his deteriorating clinical picture despite IV and otic antibiotics, neurosurgical consultation was obtained and MRI performed to assess the intracranial contents (Figure 2, 3). Based on this, cortical mastoidectomy was performed, and per the neurosurgeon's recommendation, no removal of sigmoid sinus thrombus was performed. The patient made a gradual full recovery without residual neurologic deficit, though temporary tracheostomy was required due to prolonged intubation.
Currently, there are about 183,000 patients living with a solid organ transplant, and consequently, living in a medically induced immunocompromised state. (4) Over the past decade, both the total number of operations as well as the one and five-year success rates of organ transplantation have increased. (4) Therefore, an increased number of post-transplant patients are living longer, immunosuppressed lives. As we move forward, there will be an increasing need for physicians capable of managing complications in this growing patient population.
A specific set of complications faced by this patient population is vulnerability to complicated head and neck infection. Acute otomastoiditis is a disease typically thought to affect the pediatric population, however, it is apparent that post-transplant immunosuppression creates a clinical scenario that can lead to advanced otologic infections in adults. A MEDLINE search was undertaken, revealing a paucity of literature on complicate otitis media in solid organ transplantation patients. The weakened immune system makes the rapid progression of localized infection a significant concern to the healthcare team, and swift recognition and work up are crucial to preventing intracranial complications.
Intracranial spread of otogenic infection has been shown to have a mortality rate of 5-25%. (6,7) Most commonly, intracranial involvement presents as meningitis, however, abscess, lateral sinus thrombosis, and otitic hydrocephalous are all possible sequelae of uncontrolled disease. (8) Antibiotics play a crucial role in preventing these complications in the general population, and have decreased the incidence of intracranial spread from 2.3% to 0.24% since their clinical use began in the 1930's and 40's. (9) Although treatment strategies are somewhat controversial, some believe surgical treatment is usually necessary after medical management has failed to bring about significant improvement within 48 hours. (7) Watchful waiting for the effects of medical therapy may not be the optimum plan of action in a patient with a weakened immune system. Antibiotics along with immunosuppression may mask the symptoms of disease progression by lessening the inflammatory response mounted in the presence of intracranial spread. (9) With this in mind, the combination of antibiotic therapy and early surgical treatment should be strongly considered in management of acute otomastoiditis in the immunosuppressed patient.
Additionally, it has been shown that a significant number of cases of otomastoiditis could be attributable to presence of a cholesteatoma and chronic suppurative otitis media. (10,11) Surgical intervention is typically needed when definitively treating both of these conditions, therefore, early surgery in immunocompromised individuals may not only provide a cure for a current infection, but may also serve to prevent further complications due to chronic middle ear disease.
It is also important to note that early surgical intervention not only has a role in the prevention of intracranial spread of infection, but that mastoidectomy can also be performed at the time of a surgical intervention indicated for an already established intracranial complication of otomastoiditis. Singh and Maharaj (10) suggested that if the patient can tolerate being under anesthesia for the necessary time, mastoidectomy should be performed concurrently with any indicated neurosurgical procedure such as abscess drainage. (11) Their findings support the notion that delaying mastoid surgery fails to rid area of the origin of infection and that complete treatment is not reached until mastoidectomy is performed. (12) Ultimately, however, it is important that the various surgical teams should coordinate the timing and sequence of surgical treatment.
Otomastoiditis in a solid organ transplant patient is a disease that requires aggressive medical and surgical treatment to prevent progression of disease and rid the patient of infection. Advanced disease can lead to intracranial complications that carry a concerning mortality rate. Therefore, a high level of suspicion and prompt recognition are important for treating these, as in other, immnocompromised patients. Although surgical treatment may be withheld until after a trial of antibiotics in immunocompetent patients, early surgical debridement with mastoidectomy should be encouraged in patients whose immune systems are weakened or suppressed by anti-rejection medications if a rapid response to medical therapy does not occur.
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(2.) Reyna J, Richardson JM, Mattox DE, Banowsky LH, Nicastro-Lutton JJ. Head and neck infection after renal transplantation. JAMA. Jun 25 1982; 247(24):33373339.
(3.) Marsot-Dupuch K, Quillard J, Meyohas MC. Head and neck lesions in the immunocompromised host. Eur Radiol. Mar 2004; 14 Suppl 3:E155-167.
(4.) U.S. Department of Health and Human Services, Health Resources and Services Administration. 2009 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1999-2008. U.S. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD
(5.) Migirov L, Duvdevani S, Kronenberg J. Otogenic intracranial complications: a review of 28 cases. Acta Otolaryngol. Aug 2005; 125(8):819-822.
(6.) Turgut S, Ercan I, Alkan Z, Cakir B. A case of pneumocephalus and meningitis as a complication of silent otitis media. Ear Nose Throat J. Jan 2004; 83(1):50-52.
(7.) Barry B, Delattre J, Vie F, Bedos JP, Gehanno P Otogenic intracranial infections in adults. Laryngoscope. Mar 1999; 109(3):483-487.
(8.) Nissen AJ, Bui H. Complications of chronic otitis media. Ear Nose Throat J. May 1996; 75(5):284-292.
(9.) Go C, Bernstein JM, de Jong AL, Sulek M, Friedman EM. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol. Apr 15 2000; 52(2):143148.
(10.) Shamboul KM. An unusual prevalence of complications of chronic suppurative otitis media in young adults. J Laryngol Otol. Oct 1992; 106(10):874-877.
(11.) Singh B, Maharaj TJ. Radical mastoidectomy: its place in otitic intracranial complications. J Laryngol Otol. Dec 1993; 107(12):1113-1118.
(12.) Hafidh MA, Keogh I, Walsh RM, Walsh M, Rawluk D. Otogenic intracranial complications. A 7-year retrospective review. Am J Otolaryngol. Nov-Dec 2006; 27(6):390-395.
Douglas Hildrew, M.D., Austin Adams, M.D., Ryan Winters, M.D., Rizwan Aslam, D.O., M.S. All authors are associated with Tulane University Department of Otolaryngology--Head & Neck Surgery.
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|Author:||Hildrew, Douglas; Adams, Austin; Winters, Ryan; Aslam, Rizwan|
|Publication:||The Journal of the Louisiana State Medical Society|
|Article Type:||Clinical report|
|Date:||May 1, 2016|
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