3.5. Repeated imaging and surgery
Seven of the 33 patients required a second imaging study performed on average on POD5, and all belonged to MCG. The indication for performing second imaging was continuous fever. No new complications were found on any of the repeated imaging. Five patients (15%) underwent second surgical procedure, performed after an average time of 4 days following the first surgery. Four of them were from MCG and an additional single patient was from SCG. One patient had an examination under anaesthesia, and two additional patients had reinsertion of a VT. Two (6%) patients underwent a second surgical procedure due to prolonged POF.
4. Discussion
The present study addresses the detailed post-operative course of fever in pediatric patients presented with CAM and underwent surgical treatment.
Most AM cases are managed conservatively, with myringotomy, intravenous antibiotics, and a careful follow-up, until resolution of the disease. In cases of complications, either extra or intra-cranial, surgery is generally indicated, while continuing systemic antibiotic treatment. The surgical management may differ between various medical centers and includes myringotomy, placement of VT, and incision plus drainage of SPA, with or without cortical mastoidectomy (6). In a series of 570 children published recently from Israel, reported a significant increase in AM cases that had an indication for surgical intervention during the years 2008-2017 (11% vs. 19% between the first and the last five years of the study respectively, P = 0.008) and described higher fever, leukocytes counts and CRP values in CAM compared to simple AM (7). A study from the UK(8), described 30 patients (aged 2 months to 15 years) with intracranial complications of AM. The most frequent complication was SST (73%), followed by a cerebral abscess (40%) and SPA (33%). Three (10%) patients had long-term sequelae (one developed secondary intracranial hypertension, the second a CSF leak that required placement of a ventriculo-peritoneal shunt, and the third with diplopia and residual mild visual obscuration); only one (3%) patient required additional surgical treatment. In a recent study from the United States, addressing the safety and post-operative adverse events encountered during the management of AM (9), 113 patients with AM requiring surgical treatment were analyzed. Four (3.1%) patients required readmission and 9 (6.9%) required unplanned subsequent operative procedures.