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\begin{document}

\title{Post-operative fever in children undergoing mastoidectomy due to
complicated acute mastoiditis}



\author[1]{Oren Ziv}%
\author[1]{Aviad Sapir}%
\author[1]{Eugene  Leibowitz}%
\author[1]{Sofia Kordeluk}%
\author[2]{Daniel KAPLAN}%
\author[3]{Sabri El-Saied}%
\affil[1]{Soroka Medical Center}%
\affil[2]{Soroka University Medical center}%
\affil[3]{SoSoroka University Medical Center}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Abstract Objectives: To determine the immediate post-operative course
and outcome of pediatric patients with complicated acute mastoiditis
(CAM) following surgical treatment. Study Design: A retrospective chart
review of children diagnosed with CAM who underwent mastoid surgery
during 2012-2019. Setting: Tertiary care university hospital.
Participants: the study includes 33 patients, divided into two groups:
17 patients with subperiosteal abscess (SPA) alone - single complication
group (SCG) and 16 patients with SPA and additional intracranial or
intratemporal complications -multiple complications group (MCG). Main
Outcome Measures: post-operative fever course and pattern (POF). Results
:33 patients belong to the SCG 17(51\%) and 16(49\%) belonged to the
MCG, respectively. 6/17(35.3\%) SCG patients experienced POF vs.
12/16(75\%) in the MCG (P=0.012). At post-operative day 2 (POD2),
10/13(77\%) febrile patients belonged to MCG and 3/13(23\%) to SCG
(P=0.013). POF was recorded until POD6 in both groups. Seven patients,
all from MCG with POF, underwent second imaging with no new findings.
Conclusion: Following a cortical mastoidectomy for CAM, POF is not
unusual in the first 6 days and seem to be benign condition. POF is more
common, higher, and persistent for a longer duration in MCG compared
with SCG. At POD 6, fever is expected to normalize in both groups, so if
fever persists further evaluation should be considered.%
\end{abstract}%



\sloppy


\textbf{Key points:}

1. Thirty-three patients with complicated acute mastoiditis from a
tertiary medical center were included in this retrospective cohort
study.

2. Patients were divided into two study groups: Patients with
sub-periosteal abscess alone- single compilation group, and patients
with additional complications- multiple complication group.

3. Post-operative fever after cortical mastoidectomy due to complicated
acute mastoiditis seems to be a benign condition in the 5-6 days
postoperative period

4. The multiple complication group exhibited higher and prolonged
post-operative fever compared to single complication cases.

\textbf{1. Introduction}

The most Common complications seen in children with acute mastoiditis
include sub-periosteal abscess (SPA), sigmoid sinus thrombosis (SST),
peri-sinus fluid/abscess, epidural, subdural abscess, and acute
meningitis \textsuperscript{(1-2)}. These complications are diagnosed
both, clinically and radiologically \textsuperscript{(3)}. Cortical
mastoidectomy with ventilation tube insertion has a vital role in
treating complicated mastoiditis (CAM), along with
antibiotics\textsuperscript{(4)}, antipyretics, and anticoagulation, in
cases of SST \textsuperscript{(5)}.

The management of a febrile child with CAM regardless of clinical
improvement becomes challenging. In such cases, repeated imaging and
revision surgery should be considered. However, imaging in such
circumstances possesses several limitations; Post-contrast head CT in
children usually requires general anesthesia and is associated with
substantial ionizing radiation. Head MRI is superior over CT for
evaluating soft tissue details such as of peri-sinus abscess and
presence of SST but is less available, costly, and requires an extended
general anesthesia period.

The main aim of the present study was to characterize the incidence and
course of post-operative fever (POF) in children with CAM following
surgery

\textbf{2. Materials and methods}

The STROBE methodology Guidelines were applied in this cohort
retrospective study.

\textbf{2.1. Ethical considerations:}

The study was approved by {[}Blinded for review{]} Medical Center's
Ethics committee.

\textbf{2.2. Participants}

patients that underwent cortical mastoidectomy due to complicated
mastoiditis at {[}Blinded for review{]} between 2012\textbf{-} 2019 were
reviewed\textbf{.} Data collected included demographics, laboratory
parameters at admission and at surgery day.

\textbf{2.3. Fever}

Post-operative body temperature was assessed every eight hours via
rectal or axillary route and fever was defined as any body temperature
of [?]38.0\selectlanguage{ngerman}°C.

\textbf{2.4. Treatment and complication grouping}

Single complication group (SCG) included all children diagnosed with
acute mastoiditis and isolated SPA. Multi complications group (MCG)
included patients with additional intratemporal or intracranial
complication (peri-sinus fluid/abscess, epidural abscess, SST, acute
meningitis).

\textbf{2.5. Statistical analysis}

Patient characteristics are presented as mean SD for continuous
variables with normal distribution and categorical variables presented
as a percentage. Continuous variables were examined using the student's
t-test. Categorical variables were compared using the chi-square test.
Data were analyzed using the Statistical Package for Social Sciences
(IBM SPSS Chicago, USA, version 22). In all analyses, alpha level was
set to 0.05.

\textbf{3. Results}

\textbf{3.1. Demographics and inflammatory parameters at presentation}

Thirty-three patients with CAM who underwent a cortical mastoidectomy
and ipsilateral ventilation tube insertion were identified. Demographics
and clinical data are shown in \textbf{Table 1} . Hospitalization length
was significantly higher in MCG, (12.4±6.6 \emph{vs} . 7.5±2.5 days in
the SCG P = 0.008). WBC counts and CRP values at admission were 19,782
cells/mm\textsuperscript{3} and 124.25 mg/dl in the SCG compared with
16,524 cells/mm\textsuperscript{3}and 129.19 mg/dl in the MCG,
respectively (P = 0.229 and P = 0.89, respectively). No significant
differences were found between study groups regarding mean body
temperature measurements, CRP levels, and WBC counts recorded on the day
of surgery.

\textbf{3.2. Timing of surgery and laboratory findings}

Surgery was performed on days 1-5 of hospitalization (three patients on
day 1, eighteen on day 2, eight on day 3, three on day 4, and one on day
5), with no difference between the groups in respect to mean timing for
surgery (2.47 ± 0.8 days after admission in the SCG \emph{vs} . 2.37 ±
0.9 days in the MCG, P=0.766).

\textbf{3.3. Imaging}

All patients underwent post-contrast head CT and temporal bone high
resolution CT (TBHRCT) prior to surgery. Imaging demonstrated 17 (51\%)
children with isolated SPA alone, six (18\%) SPA with SST, four (12\%)
SPA with peri-sinus collection, four (12\%) SPA, SST and peri-sinus
collection. One (3\%) child had SST with epidural abscess and one (3\%)
child had SPA with epidural abscess.

\textbf{3.4. Post-operative fever}

Both SCG and MCG exhibited POF, yet magnitude and duration significantly
differed between the two groups as shown in (\textbf{Figure
1),}6/17(35.3\%) SCG patients experienced fever at some point
post-operatively \emph{vs} . 12/16 (75\%) in the MCG (P = 0.012).

POF was higher and of longer duration in the MCG. At post-operative day
(POD 1) mean temperature was 37.8±0.9 in the SCG and 37.7±1 in the MCG
(P=0.71). On POD2, the mean temperature was lower in the SCG \emph{vs} .
the MCG (37.29 \emph{vs} . 38.17, P = 0.035). On POD6, the mean
temperature was lower in the SCG\emph{vs} . the MCG (37.44 \emph{vs} .
37.58, respectively, P = 0.32).

Febrile children (\selectlanguage{english}[?]38\textsuperscript{0}C) in both groups are depicted
in Figure 2. At POD2, 10/13 (77\%) febrile patients belonged to MCG and
3/13 (23\%) belonged to SCG (P = 0.013). On POD6, only one child from
the SCG had fever. This child had undergone another CT scan, and no new
complications were found.

\textbf{3.5. Repeated imaging and surgery}

Seven of the 33 patients required a second imaging study performed on
average on POD5\textbf{,} 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.

\textbf{4. Discussion}

The present study addresses the detailed post-operative course of fever
in pediatric patients presented with CAM and underwent surgical
treatment\textbf{.}

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 \textsuperscript{(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 \textsuperscript{(7)}. A study from the
UK\textsuperscript{(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 \textsuperscript{(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.

\textbf{POF and infection}

POF is a known entity in surgery in general and in ear surgery in
particular. El-Saied \emph{et al} . \textsuperscript{(10)} reported an
overall POF incidence of 19.2\% after cochlear implant surgery and
showed that POF was unrelated to infectious or local complications and
did not seem to have any long-term significance. Nevertheless, in
contrast to the AM cochlear implants is an elective and ''clean''
procedure. In the setting of CAM; an acute infectious disease requiring
surgery for purulent drainage and reduction of bacterial load, POF may
be a sign of complications, requiring further investigation and
treatment. To the best our knowledge our present study is the first to
characterize the POF course of CAM. We found that POF is different in
magnitude and duration in SCG and in MCG. We found that in any given POD
in the MCG, the fever tended to be more common and higher. Nevertheless,
around POD6, no differences were recorded in the values of fever
measured between the two study groups, and the fever normalized in most
of the patients. This is an important finding, suggesting that in a
patient with CAM, POF should be expected and does not necessarily mean
lack of control of the infection that would require repeated imaging and
possibly revision surgery.

\textbf{Repeated-imaging and revision-surgery}

Twenty-one percent (7/33) of the study patients underwent post-surgery
imaging; of them, only two patients required a second surgical
procedure. All patients underwent post-surgical imaging belonged to the
MCG. The most common findings in the repeated imaging showed only the
previously known complications and post-surgical changes. Therefore, our
study confirmed that a low percentage of patients with CAM might require
repeated imaging and revision surgery. However, since fever usually
continues in the first few PODs, waiting and close clinical follow-up
for at least 5to 6 days after surgery seems to be sufficient in most
cases before considering additional diagnostic and therapeutic steps.

\textbf{5. Conclusions}

Following a cortical mastoidectomy for CAM, POF is not unusual in the
first 6 days and seem to be benign condition. However, POF is more
common, higher, and persistent for a longer duration in MCG compared
with SCG. At POD 6, fever is expected to normalize in both groups, so if
fever persists further evaluation should be considered.

\textbf{Data Availability Statement}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\par\null

\textbf{References}

1. Loh R, Phua M, Shaw CL. Management of paediatric acute mastoiditis:
systematic review.~\emph{J Laryngol Otol} . 2018; 132:96-104.
doi:10.1017/S0022215117001840

2. Ren Y, Sethi RKV, Stankovic KM. Acute Otitis Media and Associated
Complications in United States Emergency Departments.~\emph{Otol
Neurotol} . 2018; 39:1005-1011. doi:10.1097/MAO.0000000000001929

3. Mather MW, Yates PD, Powell J, Zammit-Maempel I. Radiology of acute
mastoiditis and its complications: a pictorial review and
interpretation.~\emph{J Laryngol Otol} . 2019; 1-6.
doi:10.1017/S0022215119001609

4. Mierzwi\selectlanguage{polish}ń\selectlanguage{english}ski J, Tyra J, Haber K, et al. Therapeutic approach to
pediatric acute mastoiditis - an update.~\emph{Braz J Otorhinolaryngol}
. 2019; 85:724-732. doi:10.1016/j.bjorl.2018.06.002

5. Mather M, Musgrave K, Dawe N. Is anticoagulation beneficial in acute
mastoiditis complicated by sigmoid sinus thrombosis?~\emph{Laryngoscope}
. 2018; 128:2435-2436. doi:10.1002/lary.27151

6. Ghadersohi S, Young NM, Smith-Bronstein V, Hoff S, Billings KR.
Management of acute complicated mastoiditis at an urban, tertiary care
pediatric hospital. Laryngoscope. 2017; 127:2321-2327. doi:
10.1002/lary.26365.

7. Stern Shavit S, Raveh E, Levi L, Sokolov M, Ulanovski D. Surgical
intervention for acute mastoiditis: 10 years experience in a tertiary
children hospital.~Eur Arch Otorhinolaryngol. 2019; 276:3051-3056.
doi:10.1007/s00405-019-05606-2

8. Krishnan M, Walijee H, Jeurasa A, et al. Clinical outcomes of
intracranial complications secondary to acute mastoiditis: The Alder Hey
experience. Int J Pediatr Otorhinolaryngol. 2020; 128: 109- 115.
doi:10.1016/j.ijporl.2019.109675.

9. Crowson MG, Cheng J. Safety and post-operative adverse events in
management of acute mastoiditis in children - 30 Day NSQIP outcomes.~Int
J Pediatr Otorhinolaryngol. 2018; 108:132-136.
doi:10.1016/j.ijporl.2018.02.043

10. El-Saied S, Joshua BZ, Abu Tailakh M, et al. Early post-operative
fever in paediatric patients undergoing cochlear implant
surgery.~\emph{Clin Otolaryngol} . 2018; 43:385-388.
doi:10.1111/coa.13009

\emph{Figure/Table list:}

\textbf{Figure 1.}

\textbf{Fever patterns in CAM; comparison between SCG and MCG}

\textbf{Figure 2.}

\textbf{Post-operative fever [?]38\textsuperscript{0} C; SCG and MCG
patients}

\textbf{Table 1. 33 children with complicated acute mastoiditis;
demographic, clinical, laboratory and management parameters}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Total} \textbf{n=33}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{SCG} \textbf{n= 17}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{MCG} \textbf{n=16}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{P-Value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Sex: Male n (\%) Female n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
15 (45.45) 18 (54.54)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
9 (53) 8 (47)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
6 (37.5) 10 (62.5)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.373\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Ethnicity: Jewish n (\%) Bedouin n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
23 (69.7) 10 (30.3)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
11 (64.7\%) 6 (35.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
12 (75) 4 (25)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.52\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age at hospitalization (mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.63 (\selectlanguage{ngerman}± 3.05)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.25 (\selectlanguage{ngerman}± 2.83)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.04 (\selectlanguage{ngerman}± 3.31)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.469\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Hospitalization length (days, mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
9.9 (\selectlanguage{ngerman}± 5.46)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
7.52 (\selectlanguage{ngerman}± 2.57)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
12.43 (\selectlanguage{ngerman}± 6.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{0.008}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Fever at admission (C\selectlanguage{ngerman}°, mean ± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38.30 (\selectlanguage{ngerman}± 1.22)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38.12 (\selectlanguage{ngerman}± 1.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38.5 (\selectlanguage{ngerman}± 1.35)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.386\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
WBC at admission (cells/mm3, mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18,203 (\selectlanguage{ngerman}±7,677)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19,782 (\selectlanguage{ngerman}± 7,101)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16,524 (\selectlanguage{ngerman}± 8,130)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.229\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CRP at admission (mg/dl, mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
126.72 (\selectlanguage{ngerman}±95.15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
124.25 (\selectlanguage{ngerman}±102.9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
129.19 (\selectlanguage{ngerman}±93.17)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.891\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Fever at day of surgery (C\selectlanguage{ngerman}°, mean ± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
37.96 (\selectlanguage{ngerman}± 1.15)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
37.93 (\selectlanguage{ngerman}±1.05)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
37.98 (\selectlanguage{ngerman}±1.27)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.899\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
WBC at day of surgery (cells/mm\textsuperscript{3}, mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16,583 (\selectlanguage{ngerman}± 6,807)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14,562 (\selectlanguage{ngerman}± 6,613)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18,154 (\selectlanguage{ngerman}± 6,908)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.311\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
CRP at day of surgery (mg/dl, mean \selectlanguage{ngerman}± SD)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
104.0 (\selectlanguage{ngerman}± 93.2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
95.15 (\selectlanguage{ngerman}± 35.9)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
114.12 (\selectlanguage{ngerman}± 96.2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.639\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CRP -- C-reactive protein, WBC- white blood count, SCG -- single
complication group, MCG -- multiple complications group\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure-1-COA/figure-1-COA}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure-2-COA/figure-2-COA}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

