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ACUTE MASTOIDITIS
Introduction
Mastoiditis is a suppurative infection of the mastoid air cells, most often seen in
young children.
It is usually the result of extension of an acute otitis media into the mastoid air cells
with suppuration and bone necrosis.
Acute mastoiditis is a suppurative infection of the mastoid air cells with symptoms of
less than one month’s duration.
Relatively common in the pre-antibiotic era it is now much less so in the postantibiotic age.
However it is an essential condition to recognize as serious / life -threatening
complications may occur due to the mastoids’ proximity to vital structures.
Anatomy
Anatomy of the mastoid 1
Pathology
Classification of mastoiditis:
1.
Acute mastoiditis with periosteitis (also called incipient mastoiditis) is
defined
by the presence of purulent material in the mastoid cavities.
2.
Coalescent mastoiditis (also called “acute mastoid osteitis”) is defined by
destruction of the thin bony septae between air cells. It may be followed by the
formation of abscess cavities and the dissection of pus into adjacent areas.
3.
Masked mastoiditis (also called subacute mastoiditis) refers to low-grade but
persistent infection in the middle ear and mastoid with destruction of the bony
septae between air cells.
It occurs in patients with persistent middle-ear effusion or recurrent episodes
of acute otitis media (AOM) without sufficient antimicrobial therapy.
4.
Chronic mastoiditis is a suppurative infection of the mastoid air cells of longstanding duration (months to years).
Organisms:
These include:
●
Streptococcus pneumoniae
●
Streptococcus pyogenes
●
Staphylococcus aureus
●
P. aeruginosa:
♥
This is a potential pathogen in children with acute mastoiditis who
have a history of recurrent acute otitis media and recent antibiotic use.
Complications
These are rare in the post antibiotic era, but can include serious life-threatening
conditions such as:
1.
2.
Extension to meninges resulting in:
●
Meningitis
●
Subdural abscess
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Epidural abscess.
Extension to the sigmoid sinus resulting in:
●
3.
Septic venous thrombosis.
Extension to adjacent brain tissue resulting in:
●
Cerebral abscess formation:
♥
4.
Temporal lobe/ cerebellum.
Facial nerve damage:
●
Facial nerve palsy can result from infection or inflammatory
compression of the facial nerve as it traverses the narrow canal in the petrous
portion of
the temporal bone.
5.
Bacterial labyrinthitis:
●
.
Inflammation or infection of the bony labyrinth may cause labyrinthitis
Clinical features of labyrinthitis include tinnitus, hearing loss, nausea,
vomiting, dizziness, vertigo, and nystagmus.
6.
Post auricular subperiosteal abscess:
●
Signs of subperiosteal abscess include erythema, fluctuance, and a
tender mass overlying the mastoid bone.
7.
Sternocleidomastoid muscle abscess, (Bezold abscess).
8.
Hearing loss:
Acute mastoiditis may result in transient hearing loss due to:
9.
●
Obstruction of the external auditory canal and/or middle ear effusion
●
Permanent hearing loss due to damage to the ossicles of the middle ear
●
Suppurative labyrinthitis causing damage to the cochlea.
Osteomyelitis to adjacent bone.
Serious complications of mastoiditis (M. Williams)
Clinical Features
The clinical spectrum of mastoiditis ranges from a lack of symptoms with
spontaneous resolution to progressive disease with life-threatening complications.
The characteristic features of acute coalescent mastoiditis include:
1.
Patient is febrile (around 75% of cases) and appears ill
2.
Signs of inflammation at the mastoid process:
●
Pain over mastoid process.
●
Tenderness over mastoid process.
●
Erythema/ inflammation over mastoid process.
3.
Swelling, which may result in displacement of the ear downward and outward,
with obliteration of the sulcus.
4.
Auricular discharge
5.
The tympanic membrane is inflamed or perforated. A normal tympanic
membrane
makes acute mastoiditis less likely.
6.
There may be associated deafness.
Left: Left sided acute mastoiditis, with typical downward and outward displacement
of the pinna. Right: Acute mastoiditis, with typical appearance of post-auricular
inflammation.
Investigations
Blood tests:
1.
FBE
2.
CRP
3.
U&Es/ glucose
Microbiology:
Swab any discharge from the ear for micro, culture and sensitivities.
CT scan
This will confirm diagnosis and will show complications, such as local extension or
venous sinus thrombosis.
This investigation should not delay initiation of antibiotic treatment in unwell
patients.
CT with contrast is used for suspected intracranial complications.
MRI:
May be used for suspected intracranial complications.
Management
If the condition is suspected:
1.
Analgesia as required.
2.
Urgent IV antibiotics:
●
Ceftriaxone or cefotaxime is a suitable initial empiric treatment.
●
be
Vancomycin and extended spectrum penicillins or cephalosporins will
required in more serious illness.
3.
IV fluids, as clinically indicated.
4.
Surgical drainage is usually required.
Disposition:
All suspected cases should be referred to the ENT Unit urgently