Mastoiditis

Key Features

Essentials of Diagnosis

• Acute otitis media is almost always present

• Postauricular pain and erythema

• Ear protrusion (late finding)

General Considerations

• 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

Clinical Findings

Symptoms and Signs

• 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

Differential Diagnosis

• Lymphadenitis

• Parotitis

• Trauma

• Tumor

• Histiocytosis

• Otitis externa

• Furuncle

Diagnosis

• 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.

Treatment

• 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

Outcome

Complications

• Meningitis

• Brain abscess

• Facial palsy

• Sigmoid sinus thrombosis, cavernous sinus thrombosis

• Epidural abscess

• Thrombophlebitis

Prognosis

• Good

• Children ...