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Mastoiditis, Emergency Medicine

Basics

Description

- Chronic mastoiditis: - Mastoiditis can be a complication of a primary disorder: - Leukemia - Mononucleosis - Sarcoma of the temporal bone - HIV - Kawasaki disease

- Organisms in acute mastoiditis are similar to those in acute otitis media, but differ in frequency: - Streptococcus pneumoniae - Group A streptococcus - Staphylococcus aureus - Haemophilus influenzae

- Gram-negative enteric bacteria most common with chronic mastoiditis: - Pseudomonas aeruginosa - Escherichia coli - Proteus mirabilis - Bacteroides species

- Other less common causes: - Mycobacterium tuberculosis - Aspergillus species in immunocompromised states

- Initiate IV antibiotics - Otolaryngologist consult for surgical drainage: - Drainage is the definitive therapy for acute or coalescent mastoiditis - Emergent drainage if the patient appears toxic - Types of surgical procedures: - Myringotomy drainage and tympanostomy tube placement - Mastoidectomy and drainage for severe extension (needed in ’ Ό50% of cases)

- Osteomyelitis of the calvarium - Intracranial complications: - Subperiosteal abscess - Subdural empyema: - Extension of infection to CNS with empyema around the tentorium

  • Inflammation of the mastoid air cells of the temporal bone, generally caused by direct extension of acute purulent otitis media
  • Middle ear and mastoid air cells are contiguous via the aditus to mastoid antrum
  • Fluid accumulation from closure of channel due to otitis media creates opportunity for infection
  • Manifestation ranges from clinically insignificant inflammation of mastoid air cells to infection and destruction of the bone
  • Acute mastoiditis:Occurs to some degree in all cases of otitis mediaEarly signs and symptoms are those of acute otitis mediaUsually secondary to contamination with infectious material trapped in the mastoid by inflammatory obstruction of the channel between middle ear and mastoid air cells
  • Acute mastoiditis with periostitis:As infection progresses, periosteum of the mastoid bone is involved, causing periostitisSubperiosteal abscess may be present
  • Acute mastoid ostitis (also called coalescent mastoiditis):Progression of the infection within the mastoid air cells leads to destruction of the mastoid trabeculae, causing coalescence of bony trabeculaeMastoid empyema or a draining fistula may be presentMay progress to severe head and neck complications if untreated
  • Masked mastoiditis:Mastoid infection, which lingers after an acute otitis media has been treatedMay progress to acute or coalescent mastoiditis
  • Chronic mastoiditis:
  • Mastoiditis can be a complication of a primary disorder:LeukemiaMononucleosisSarcoma of the temporal boneHIVKawasaki disease
  • Mastoiditis used to be more common prior to the use of antibiotics for acute otitis media
  • More common in young children and infants

Etiology

  • Organisms in acute mastoiditis are similar to those in acute otitis media, but differ in frequency:Streptococcus pneumoniaeGroup A streptococcusStaphylococcus aureusHaemophilus influenzae
  • Gram-negative enteric bacteria most common with chronic mastoiditis:Pseudomonas aeruginosaEscherichia coliProteus mirabilisBacteroides species
  • Other less common causes:Mycobacterium tuberculosisAspergillus species in immunocompromised states
  • More frequently seen in the pediatric population due to strong association with otitis media
  • S. pneumoniae is the most common cause in children

Diagnosis

Signs and Symptoms

History

  • Ear pain
  • Otorrhea
  • Mild to severe hearing loss
  • Fever
  • Headache
  • History of irritability in a child
  • History of recurrent otitis media

Physical Exam

  • Tenderness, edema, and erythema over the mastoid
  • Lateral and inferior displacement of the auricle
  • Loss of the postauricular crease
  • Swelling of the posterior and superior ear canal wall
  • Tympanic membrane abnormalities consistent with severe otitis media
  • Purulent fluid drainage from the auditory canal
  • Bulging tympanic membrane

Essential Workup

Mastoiditis is a clinical diagnosis

Diagnosis Tests & Interpretation

Lab

  • CBC:
  • Cultures of drainage important owing to diversity of organisms:If spontaneous drainage present or after surgical drainage
  • Blood cultures if patient appears toxic

Imaging

  • Mastoid plain radiographs:Early stage of disease may show hazy or cloudy but intact mastoidMay reveal opacification or coalescence of the mastoid air cells or coalescence as disease progressesUnreliable due to low sensitivity
  • CT scan:More useful, especially if abscess formation presentCan determine presence and extent of destruction of trabeculae as well as evaluate for the complications of mastoiditis
  • MRI:If intracranial involvement suspected but not confirmed by CT
  • Conservative use of CT in children may be warranted
  • The diagnosis can often be made on clinical grounds and avoids radiation exposure

Diagnostic Procedures/Surgery

Lumbar puncture:

  • Cerebrospinal fluid evaluation for signs of meningitis

Differential Diagnosis

  • Otitis media
  • Cellulitis
  • External otitis media
  • Scalp infection with inflammation of posterior auricular nodes
  • Rubella: Posterior auricular node enlargement
  • Trauma to pinna or postauricular area
  • Meningitis

Treatment

Initial Stabilization/Therapy

  • ABCs
  • Airway management for signs of airway compromise
  • 0.9% NS IV fluid bolus for hypotension/volume depletion

Ed Treatment/Procedures

  • Initiate IV antibiotics
  • Otolaryngologist consult for surgical drainage:Drainage is the definitive therapy for acute or coalescent mastoiditisEmergent drainage if the patient appears toxicTypes of surgical procedures:Myringotomy drainage and tympanostomy tube placementMastoidectomy and drainage for severe extension (needed in ’ Ό50% of cases)

Medication

  • Initiate IV antibiotics:Given increasing proportion of S. aureus as causative organism, consider including antistaphylococcal agent before culture resultsParenteral antibiotics can be switched to PO after patient afebrile for 36 " 48 hrConsider antipseudomonal coverage when appropriate
  • Administer pain medications:NSAIDsPO or parenteral narcotics

First Line

  • Ceftriaxone: 1 " 2 g (peds: 50 " 75 mg/kg/24 h) IV q12 " 24 h
  • Cefotaxime: 1 " 2 g (peds: 50 " 180 mg/kg/24 h) IV q4 " 6h

Second Line

  • Ampicillin/sulbactam: 1.5 " 3 g IV q6h
  • Chloramphenicol: 50 " 100 mg/kg/24 h IV or PO q6h
  • Clindamycin: 600 " 2,700 mg/d IV div. q6 " 12h or 150 " 450 mg PO q6 " 8h (peds: 20 " 40 mg/kg/d IM/IV div. q6 " 8h or 10 " 25 mg/kg/d PO div. q6 " 8h)
  • Ticarcillin/clavulanate: 3.1 g IV q4 " 6h
  • Piperacillin/tazobactam: 3.375 g IV q6h
  • Vancomycin: 1 g q8h (peds 40 mg/kg/24 h) IV q6 " 8h

Follow-Up

Disposition

Admission Criteria

  • Clinical suspicion of acute or coalescent mastoiditis
  • Subperiosteal abscess
  • Toxic appearing

Discharge Criteria

Patients with acute or coalescent mastoiditis should not be discharged

Issues for Referral

  • Otolaryngologist consult for possible surgical drainage
  • Audiography should be performed after resolution of mastoiditis to assess hearing loss

Followup Recommendations

Patients should follow up with otolaryngologist after discharge, if not admitted

Complications

  • Bezold abscess:Extension of infection to soft tissue below pinna or behind the sternocleidomastoid muscle of neck after erosion through the mastoid tip
  • Petrositis:Spread of the infection to the petrous air cells
  • Osteomyelitis of the calvarium
  • Intracranial complications:Subperiosteal abscessSubdural empyema:Extension of infection to CNS with empyema around the tentoriumSinus thromboses

Even with conservative management of otitis media, a 10-yr analysis did not show a significant increase in cases of acute mastoiditis.

Pearls and Pitfalls

  • It is important to maintain a high index of suspicion for mastoiditis in setting of persistent or untreated acute otitis media.
  • Failure to recognize meningitis or intracranial involvement, which require more aggressive management, is a pitfall
  • Drainage is the definitive therapy

Additional Reading

  • Anderson KJ. Mastoiditis. Pediatr Rev. 2009;30:233 " 234.
  • Anthonsen K, H Έstmark K, Hansen S, et al. Acute mastoiditis in children. A 10-year retrospective and validated multicenter study. Pediatr Infect Dis J. 2013;32:436 " 440.
  • Devan PP. Mastoiditis. Emergency medicine. Emedicine. Available at http://emedicine.medscape.com/article/784176-overview.
  • Liao YJ, Liu TC. Images in clinical medicine. Mastoiditis. N Engl J Med. 2013;368:2014.
  • Marx JA, Hockberger RS, Walls RM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
  • Tamir S, Schwartz Y, Peleg U, et al. Acute mastoiditis in children: Is computed tomography always necessary? Ann Otol Rhinol Laryngol. 2009;118:565 " 569.
  • Tamir S, Schwartz Y, Peleg U, et al. Shifting trends: Mastoiditis from a surgical to a medical disease. Am J Otolaryngol. 2010;31:467 " 471.

Codes

ICD9

  • 383.00 Acute mastoiditis without complications
  • 383.01 Subperiosteal abscess of mastoid
  • 383.9 Unspecified mastoiditis
  • 383.1 Chronic mastoiditis
  • 383.02 Acute mastoiditis with other complications
  • 383.0 Acute mastoiditis

ICD10

  • H70.009 Acute mastoiditis without complications, unspecified ear
  • H70.019 Subperiosteal abscess of mastoid, unspecified ear
  • H70.90 Unspecified mastoiditis, unspecified ear
  • H70.10 Chronic mastoiditis, unspecified ear
  • H70.001 Acute mastoiditis without complications, right ear
  • H70.002 Acute mastoiditis without complications, left ear
  • H70.003 Acute mastoiditis without complications, bilateral
  • H70.00 Acute mastoiditis without complications
  • H70.011 Subperiosteal abscess of mastoid, right ear
  • H70.012 Subperiosteal abscess of mastoid, left ear
  • H70.013 Subperiosteal abscess of mastoid, bilateral
  • H70.01 Subperiosteal abscess of mastoid
  • H70.11 Chronic mastoiditis, right ear
  • H70.12 Chronic mastoiditis, left ear
  • H70.13 Chronic mastoiditis, bilateral
  • H70.1 Chronic mastoiditis
  • H70.891 Other mastoiditis and related conditions, right ear
  • H70.892 Other mastoiditis and related conditions, left ear
  • H70.893 Other mastoiditis and related conditions, bilateral
  • H70.899 Other mastoiditis and related conditions, unspecified ear
  • H70.89 Other mastoiditis and related conditions

SNOMED

  • 52404001 mastoiditis (disorder)
  • 386034005 Acute mastoiditis
  • 72102005 Subperiosteal abscess of mastoid
  • 80645004 chronic mastoiditis (disorder)