Chapter 23: Mastoiditis

Patient Story

A 12-month-old girl presents to your office with 1-day history of fever and increasing swelling and redness behind her left ear. On examination, the left auricle is protruding and there is marked erythema, swelling, tenderness, and fluctuance overlying the left mastoid bone (Figure 23-1). Otoscopy reveals a purulent middle ear effusion. A computed tomography (CT) scan of the temporal bones reveals opacification of the mastoid air cells. A diagnosis of acute mastoiditis is made and the girl undergoes urgent myringotomy and tympanostomy tube placement and mastoidectomy. Postoperatively, she is treated with intravenous antibiotics and recovers completely.

Introduction

Mastoiditis is a complication of otitis media, characterized by a suppurative infection of the mastoid air cells.¹ Acute mastoiditis refers to the finding of acute otitis media on otoscopy in conjunction with local inflammatory findings in the mastoid including erythema, edema, and auricular protrusion, with duration of symptoms less than one month. Coalescent mastoiditis occurs when there is an acute otitis media which progresses into an acute infection of mastoid with osteolytic changes in the bone and destruction of the mastoid air cells. Chronic mastoiditis is defined by the presence of long-standing infection in the presence of tympanic membrane perforation or tympanostomy tube or as a complication of cholesteatoma. Chronic mastoiditis follows an indolent course of infection.

Synonyms

Mastoid inflammation or Mastoid infection.

Epidemiology

• The epidemiology of acute mastoiditis is similar to that of otitis media. Thus, acute and coalescent mastoiditis occurs most frequently in children less than 4 years of age.²

• Although recurrent otitis media is a risk factor for mastoiditis, a significant percentage of cases of mastoiditis occur in young children who do not have a prior history of OM.²

• Few studies on the incidence of mastoiditis are population based; thus it is difficult to estimate the true incidence and whether the incidence is increasing.

• Chronic mastoiditis tends to occur in children with chronic otitis media, chronic otorrhea thru tympanic membrane perforation, and/or cholesteatoma.¹

Etiology and Pathophysiology

• Acute and coalescent mastoiditis may occur in children with well pneumatized mastoids with little or minimal prior history of otitis media.

• These acute infections also occur in younger children with more immature immune systems.²

• The infectious process usually begins with an acute otitis media that causes edema of the mucoperiosteal lining of the mastoid air cells and middle ear. This blocks the aditus of the mastoid and the Eustachian tube thereby disrupting the normal aeration.^1,3 This leads to worsening purulence and inflammation ...