Subacute Mastoiditis Without Verified Nontuberculous Mycobacteria-Still a Clinical Challenge

An indolent form of mastoiditis has gained increased attention lately, challenging clinicians both regarding diagnosis as well as treatment. The etiology behind this assumed infection herein named subacute mastoiditis (SAM) is unknown; however, a link to nontuberculous mycobacteria (NTM) infections has been seen. A survey on pediatric cases with SAM over 20 years was performed to investigate the typical clinical features and to identify optimal treatment strategies for this condition, causing aggressive temporal bone destructions along with intratemporal and intracranial complications.

A retrospective survey of pediatric patients (0-17 years) hospitalized with SAM during 2003-2023 at Karolinska University Hospital, Sweden, was conducted. Data collection included demographics, diagnostics (radiology, microbiology, histopathology), treatment, and clinical outcome.

Sixteen cases (median age 7.5 years) with SAM were included. Longstanding otorrhea from ventilation tubes preceded clinical signs of mastoiditis in most cases. CT scan generally revealed cortical temporal bone destructions close to the ear canal and sigmoid sinus. Histopathological examination displayed a high incidence of granulomatous inflammation. Upon microbiological testing, six cases revealed NTM infection. All cases underwent mastoidectomy, and 11 cases received long-term mycobacteria-targeted antibiotics. No deaths occurred, but seven cases had a delayed recovery or relapsing disease, and several cases experienced complications. The long-term outcomes were good. Two cases with Mycobacterium tuberculosis mastoiditis were identified, entailing diagnostic challenges.

Histopathological and microbiological sampling along with CT scan is crucial in diagnosing SAM. We suggest surgical intervention combined with empirical long-term antimycobacterial treatment for optimal recovery and outcome in SAM.

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