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Acute mastoiditis is reported to occur 2 or 3 times annually in the largest children's hospitals. We encountered an average of 1 case annually at our hospital from 1986 to 1991. During an 8-year period ending October 31, 1999, 22 patients were diagnosed and treated at our hospital. Of these, 17 presented during the last 34 months.Retrospective chart review from office and hospital records of children from infancy to age 12 years with a discharge diagnosis of acute mastoiditis who were treated from 1992 through 1999.All children were referred to one of the two pediatric otolaryngologists in our community because of forward protrusion of the auricle and retroauricular cellulitis. Eleven (50%) were <14 months old. Ninety-five percent had a concomitant ipsilateral, inflamed, bulging, immobile eardrum. Computerized tomographic imaging, performed on all patients, revealed universal cortical destruction, subperiosteal abscess or bone destruction in four and dural venous thrombosis in two. Mastoidectomy was necessary for eight children (36%) because of complications of mastoiditis (n= 4) or for failure to improve with antibiotics and myringotomy drainage (n= 4).Streptococcus pneumoniaeorStreptococcus pyogeneswas recovered from 10 of 17 children (59%) from whom cultures were obtained.Cases of acute mastoiditis have markedly increased in our suburban children's hospital. The disease was most common during infancy. Serious complications of mastoiditis occurred in four (18%) of the children in this series.