key: cord-0682635-dd3wmx1d authors: Smith, Matthew E.; Jones, G. Huw; Hardman, John C.; Nichani, Jaya; Khwaja, Sadie; Bruce, Iain A.; Rea, Peter title: Acute paediatric mastoiditis in the UK before and during the COVID‐19 pandemic: A national observational study date: 2021-11-03 journal: Clin Otolaryngol DOI: 10.1111/coa.13869 sha: 49cc1b1f64d2910a2953e54d4a5ec0f2578ef618 doc_id: 682635 cord_uid: dd3wmx1d OBJECTIVES: To explore the impact of COVID‐19 on the management and outcomes of acute paediatric mastoiditis across the UK. DESIGN: National retrospective and prospective audit. SETTING: 48 UK secondary care ENT departments. PARTICIPANTS: Consecutive children aged 18 years or under, referred to ENT with a clinical diagnosis of mastoiditis. MAIN OUTCOME MEASURES: Cases were divided into Period 1 (01/11/19‐15/03/20), before the UK population were instructed to reduce social contact, and Period 2 (16/03/20‐30/04/21), following this. Periods 1 and 2 were compared for population variables, management and outcomes. Secondary analyses compared outcomes by primary treatment (medical/needle aspiration/surgical). RESULTS: 286 cases met criteria (median 4 per site, range 0–24). 9.4 cases were recorded per week in period 1 versus 2.0 in period 2, with no winter increase in cases in December 2020‐Febraury 2021. Patient age differed between periods 1 and 2 (3.2 vs 4.7 years respectively, p < 0.001). 85% of children in period 2 were tested for COVID‐19 with a single positive test. In period, 2 cases associated with P. aeruginosa significantly increased. 48.6% of children were scanned in period 1 vs 41.1% in period 2. Surgical management was used more frequently in period 1 (43.0% vs 24.3%, p = 0.001). Treatment success was high, with failure of initial management in 6.3%, and 30‐day re‐admission for recurrence in 2.1%. The adverse event rate (15.7% overall) did not vary by treatment modality or between periods 1& 2. CONCLUSION: The COVID‐19 pandemic led to a significant change in the presentation and case mix of acute paediatric mastoiditis in the UK. Mastoiditis is the most common complication of acute otitis media (AOM), 1 predominantly affecting young children and with a high rate of intracranial complications. 2 The SARS-CoV-2 (COVID-19) pandemic and the resulting societal changes have altered the presentation and frequency of many conditions seen by otolaryngologists. At the outset of the pandemic, there was concern that COVID-19 may promote acute mastoiditis, following the identification of the virus in the mastoid and middle ear, 3 with one group reporting a significant increase in complicated mastoiditis in early 2020. 4 However, it also became clear that globally there was a significant decrease in children presenting to healthcare teams with AOM, [5] [6] [7] suggesting mastoiditis should in fact be dropping in incidence. In early March 2020, established management practices in otolaryngology were disrupted in ways not seen before, in an effort to protect staff and patients from COVID-19, and to maintain capacity within the health system. Acute paediatric mastoiditis was no exception, with professional bodies in the UK recommending initial medical treatment, with curettage as primary surgical treatment 8 to avoid the potential for viral transmission (via aerosol generation) with high-speed drilling. In response to the anticipated changes in both the pathophysiology of AOM and resultant care of these patients, the objective of the present study was to explore the impact of COVID-19 on the management and outcomes of acute paediatric mastoiditis across the UK. This manuscript has been prepared with reference to the STROBE checklist for cohort studies. 9 The protocol was published in advance at https://entin tegra te.co.uk. The Health Research Authority decision tool determined the study design to fall under the remit of audit, and so no ethical approval was required (http://www.hra-decis ionto ols.org.uk/resea rch/). A national observational study of the management of acute paediatric mastoiditis by the UK secondary care ENT departments was completed. Data collection was retrospective over the 12 Consecutive children aged 18 years or under at the date of admission, and who were referred to ENT with a clinical diagnosis of acute mastoiditis (according to local team), were eligible for inclusion. The primary method for retrospective case identification was a search of ICD-10 coding using H70-derived codes (mastoiditis and related conditions). Data collection was via online electronic case report forms (eCRF, see Supplementary Material) utilising REDCap (Research Electronic Data Capture) a secure, web-based application. Quality was controlled by limited data entry, predefined data formats and range checks. eCRF variables and data fields were decided by steering committee consensus following literature review. Local site information was collected at the point of registration. Collected case data included demographics, symptoms/signs, laboratory results including COVID-19 status, computed tomography (CT) and magnetic resonance (MR) scan reports, medical and surgical management details, 30-day (from discharge) re-admission details and adverse events. Data were stored on the AIMES Health Cloud (ISO 27001 certified). Individuals treated at more than one hospital had records combined. Cases were divided into two periods representing the time before • The incidence of acute paediatric mastoiditis significantly dropped during the COVID-19 pandemic • There was no winter peak in mastoiditis cases in 2020-2021 • Compared with preceding months, mastoiditis during the pandemic was associated with lower inflammatory markers and fewer complications. • Clinicians adopted a more conservative approach to management during the pandemic, with reduced imaging and surgical intervention. • Patient outcomes were similar before and during the COVID-19 pandemic, with low rates of disease recurrence. the UK population were instructed to reduce non-essential social Secondary analyses compared outcomes by primary treatment, grouped as medical (no invasive intervention), needle aspiration (of a subperiosteal abscess) and surgical (any other invasive procedure). Secondary treatments were defined locally as an intervention required after intended medical treatment alone, or occurring after a primary operation for surgical/needle aspiration. Population differences between conservatively managed patients (ie medical management or needle aspiration) and surgically managed patients were assessed to explore clinical decision-making. Analyses were performed in Excel v16.49 (Microsoft Corp. Redmond, Washington) and SPSS v27.0 (IBM Corp. Armonk, New York). Forty-eight UK sites participated, including 16 tertiary paediatric ENT centres (see Acknowledgements). All sites submitted data covering the complete retrospective and prospective periods, with 286 cases meeting eligibility criteria (two excluded for exceeding age criteria). The median number of cases per site was 4 (range 0-24, interquartile range 2-11). A peak in mastoiditis cases was seen in the winter months The demographics and background variables for children presenting with mastoiditis are shown in Table 1 . The overall median age One or more organisms were cultured in 56.6% of cases where a sample was taken, with some more likely to be associated with intracranial complications (Table 2 ). There was a significant decrease in S. pneumoniae, group A Strep and H. influenzaeassociated mastoiditis in period 2, with P. aeruginosa significantly increasing in incidence to become the dominant organism in this period. Approximately one quarter of children in the cohort had recorded initial management in primary care, unchanged between periods 1 and 2 (Table 1) . Conversely, management in secondary care demonstrated a significant switch towards more conservative management in period 2 ( invasive procedure to increase in period 2, but overall powered drill mastoid surgery, with or without adjuvant ventilation tube insertion, remained the most frequent procedure (Figure 3) . Median time to surgery from admission was 1 day. Around 1 in 5 children were transferred between hospitals, with no difference between periods. The surgically and conservatively (medical treatment or needle aspiration) managed groups differed significantly for two variables: age (4.7 years surgical vs 5.4 conservative (p = 0.029)) and admission CRP value (86.6 mg/L surgical vs. 67.9 conservative (p = 0.002)). Other symptoms, test values and complication data were comparable between groups (full results in Table S1 ). Outcomes are presented in Table 3 . Length of inpatient stay was comparable between periods 1 and 2, and longer for patients treated surgically than medically (median 6.0 versus 2.0 days respectively). Regardless of management, treatment success was high, with failure of initial management (medical or surgical) requiring delayed surgery in 6.3% of children overall, and a 30-day Several differences between periods 1 and 2 can be seen in the population of affected children, and in the characteristics of the infections. It is hypothesised that these differences are due to the loss of the URTI-driven winter peak in infection. In line with this, the number of children with mastoiditis presenting with coryzal symptoms more than halved in period 2. This loss of the winter effect is most clearly seen in the age of patients, and in the organisms identified. In period 1, the spectrum and proportion of organisms are comparable to other series where most cases occurred in winter. 2, 15 In contrast in period 2, cases with organisms typically associated with AOM, such as S. pneumoniae and H. influenzae, were greatly reduced, with an accompanying increase in cases associated with P. aeruginosa and Candida. Camanni et al. reported cases of paediatric mastoiditis limited to summer months (June-September), finding P. aeruginosa to be the most commonly isolated organism, accounting for 51.6% of positive samples. 16 Our study did not collect data from the preceding summer to compare with period 2 unfortunately, and it is noted that P. aeruginosa can be prominent in some multi-year series. 17 most commonly affected by mastoiditis in the summer, and an association between older age and P. aeruginosa as a causative organism for mastoiditis is described 16, 18 The weekly rate of cases associated with P. aeruginosa significantly increased in period 2, which may not be expected from simply suppressing URTI-related infection. Children with Pseudomonasassociated mastoiditis are more likely to have had previous otologic problems, 18 The reported complication rate for acute paediatric mastoiditis varies from 32.7% 17 to 1.9%, 11 with our figure of 15.7% falling in the middle. Complications in our population were largely due to intracranial sequelae (14.0%), similar to published series. 2, 17, [20] [21] [22] Both blood inflammatory marker levels (white cell counts and CRP) and the rate of intracranial complications and adverse events were lower in period 2. This difference is likely due to the lack of a winter effect during the pandemic: P. aeruginosa has previously been found to be associated with lower inflammatory markers, 16, 18 and in our series was not associated with any intracranial complications. There is also evidence for lower inflammatory markers 15 and fewer complications in comparative older age groups. 13 F I G U R E 3 Type of non-medical management, as a percentage of all subjects, before (light grey bars) and after (dark grey bars) the introduction of COVID-19 measures in the UK. Bonferroni-corrected P-value for comparison of paired bars delayed or second surgery (overall 6.3%), and low recurrence rates at 30 days (overall 2.1%), suggesting outcomes were not affected by COVID-19-associated changes in mastoiditis or its management. Our data demonstrate a significant decrease in surgical management in period 2, with several possible explanations for this difference. Firstly, children in period 2 were more likely to have milder, uncomplicated mastoiditis, lending themselves to more conservative management. Secondly, within the UK and elsewhere, guidance on the management of acute mastoiditis changed, to prioritise more conservative interventions. 8 There is however little evidence of the latter promoting the change, as incision and drainage / curettage techniques reduced similarly to 'higher-risk' interventions, such as high-speed drill mastoidectomy, discouraged in many COVID-19related guidelines owing to its aerosol-generating potential. The published rate of failure to improve, requiring mastoidectomy, following initial conservative treatment is 4.3%, 24 and in our study, the figure was 2.8% for medical treatment and 28.6% for needle aspiration, though the sample size for aspiration was too small to draw conclusions. Our data confirm that medical management alone is appropriate for more than half of children who are admitted with acute mastoiditis, though the observational nature of this study prevents an understanding of the complex clinical assessment that goes into management planning. The only significant differences identified related to management choice were lower CRP and older age in the conservative treatment group, but neither is likely to be a primary driver of clinical decision-making. It is impossible to conclude from our data whether surgical management is currently over-adopted. No iatrogenic adverse events were identified, and given the potential for complications with severe acute mastoiditis, many surgeons feel surgery is justified. There has been a shift towards more conservative management and delayed surgical management 12 with evidence that needle aspiration can provide effective management of subperiosteal abscesses in some children. 19, 25 It was thought that the COVID-19 pandemic may force changes in mastoiditis management, providing lessons for future guidelines; however, findings instead appear to reflect a change in the nature of mastoiditis cases presenting. This study was completed primarily to capture emergency changes to practice and new presentations relating to COVID-19 and therefore adopted a relatively short time period and simplified dataset to ease the burden on clinicians. 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