Basics
Description
- 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 media
- Early signs and symptoms are those of acute otitis media
- Usually 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 periostitis
- Subperiosteal 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 trabeculae
- Mastoid empyema or a draining fistula may be present
- May progress to severe head and neck complications if untreated
- Masked mastoiditis:
- Mastoid infection, which lingers after an acute otitis media has been treated
- May progress to acute or coalescent mastoiditis
- Chronic mastoiditis:
- Mastoiditis can be a complication of a primary disorder:
- Leukemia
- Mononucleosis
- Sarcoma of the temporal bone
- HIV
- Kawasaki 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 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
- 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 mastoid
- May reveal opacification or coalescence of the mastoid air cells or coalescence as disease progresses
- Unreliable due to low sensitivity
- CT scan:
- More useful, especially if abscess formation present
- Can 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 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)
Medication
- Initiate IV antibiotics:
- Given increasing proportion of S. aureus as causative organism, consider including antistaphylococcal agent before culture results
- Parenteral antibiotics can be switched to PO after patient afebrile for 36 " 48 hr
- Consider antipseudomonal coverage when appropriate
- Administer pain medications:
- NSAIDs
- PO 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 abscess
- Subdural empyema:
- Extension of infection to CNS with empyema around the tentorium
- Sinus 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)