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Key Features

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Essentials of Diagnosis
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  • Acute otitis media is almost always present

  • Postauricular pain and erythema

  • Ear protrusion (late finding)

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General Considerations
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  • Occurs when infection spreads from the middle ear space to the mastoid portion of the temporal bone, which lies just behind the ear and contains air-filled spaces

  • Can range in severity from inflammation of the mastoid periosteum to bony destruction of the mastoid air cells (coalescent mastoiditis) with abscess development

  • Can occur in any age group, but more than 60% of the patients are younger than 2 years

  • Most common pathogens are Streptococcus pneumoniae followed by Haemophilus influenza and Streptococcus pyogenes

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Clinical Findings

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Symptoms and Signs
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  • Postauricular pain, fever, and an outwardly displaced pinna

  • On examination, the mastoid area often appears indurated and red and with disease progression, it may become swollen and fluctuant

  • Earliest finding is severe tenderness on mastoid palpation

  • Acute otitis media is almost always present

  • Late findings include a pinna that is pushed forward by postauricular swelling and an ear canal that is narrowed due to pressure on the posterosuperior wall from the mastoid abscess.

  • In infants younger than 1 year, the swelling occurs superior to the ear and pushes the pinna downward rather than outward

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Differential Diagnosis
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  • Lymphadenitis

  • Parotitis

  • Trauma

  • Tumor

  • Histiocytosis

  • Otitis externa

  • Furuncle

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Diagnosis

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  • CT scan determines extent of disease

  • Early mastoiditis may be radiographically indistinguishable from acute otitis media, with both showing opacification but no destruction of the mastoid air cells

  • With progression of mastoiditis, coalescence of the mastoid air cells is seen.

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Treatment

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  • Intravenous antibiotic treatment alone may be successful if there is no evidence of coalescence or abscess on CT

  • However, if there is no improvement within 24–48 hours, surgical intervention should be undertaken

  • Minimal surgical management starts with tympanostomy tube insertion, during which cultures are taken

  • If a subperiosteal abscess is present, incision and drainage is also performed, with or without a cortical mastoidectomy

  • Intracranial extension requires complete mastoidectomy with decompression of the involved area

  • Antibiotic therapy (intravenous and topical ear drops) is instituted along with surgical management and relies on culture directed antibiotic therapy for 2–3 weeks

  • An antibiotic regimen should be chosen that is able to cross the blood-brain barrier

  • After significant clinical improvement is achieved with parenteral therapy, oral antibiotics are begun and should be continued for 2–3 weeks

  • A patent tympanostomy tube must also be maintained with continued use of otic drops until drainage abates

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Outcome

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Complications
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  • Meningitis

  • Brain abscess

  • Facial palsy

  • Sigmoid sinus thrombosis, cavernous sinus thrombosis

  • Epidural abscess

  • Thrombophlebitis

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Prognosis
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  • Good

  • Children in whom acute mastoiditis with abscess develops as their first ear ...

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