Basics
Description
Infection of the mastoid air cells characterized clinically by protrusion of the pinna and erythema/tenderness over the mastoid process; can range from an asymptomatic illness to a severe life-threatening disease. Acute mastoiditis is defined as the presence of symptoms for less than 1 month.
Epidemiology
- Most patients are between 6 " 24 months old.
- Male to female ratio of 2:1
- It is unusual to see mastoiditis in young infants because of incomplete pneumatization of the mastoid air cells.
Incidence
- At the start of the 20th century, 20 " 50% of cases of otitis media developed into coalescent mastoiditis. The routine use of antibiotics for otitis media and aggressive management of treatment failures has decreased incidence to 0.2 " 0.4%.
- Although some single-site reports have suggested that mastoiditis is on the rise, larger population-based studies demonstrate a stable incidence.
Risk Factors
- Age <2 years of age
- Acute otitis media
- Recurrent otitis media
General Prevention
- Appropriate early treatment of otitis media and timely follow-up to identify treatment failures
- Avoid factors that predispose to otitis media, including caretaker smoking and bottle-feeding.
- Early recognition of mastoiditis decreases the risk of intracranial complications.
- Pneumococcal vaccination may help decrease the occurrence of otitis media.
Pathophysiology
- The mastoid process is the posterior portion of the temporal bone and consists of interconnecting air cells that drain superiorly into the middle ear. Because these mastoid air cells connect with the middle ear, all cases of acute otitis media are associated with some mastoid inflammation.
- Acute mastoiditis develops when the accumulation of purulent exudate in the middle ear does not drain through the eustachian tube or through a perforated tympanic membrane but spreads to the mastoid.
- Acute mastoiditis can progress to a coalescent phase after the bony air cells are destroyed and may then progress to subperiosteal abscess or to chronic mastoiditis.
Etiology
- Acute mastoiditis is generally caused by an extension of the inflammation and infection of acute otitis media into the mastoid air cells. However, 20 " 50% of patients may present without evidence of preceding otitis media.
- The bacteria isolated from middle ear drainage or from the mastoid are usually Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, or Staphylococcus aureus. However, many patients ' cultures are sterile:
- S. pneumoniae is the most frequently isolated cause of mastoiditis in pediatric patients. S. pneumoniae resistance to penicillin may be as high as 30%, with the 19A serotype being the most common. With the advent of the 13 valent pneumococcal vaccine (which contains the 19A serotype), the epidemiology may change.
- Pseudomonas infection should be suspected if the child has been on antibiotics recently or has a history of recurrent otitis media.
- Chronic mastoiditis is usually caused by S. aureus, anaerobic bacteria, enteric bacteria, and Pseudomonas aeruginosa:
- Chronic mastoiditis is often a multiple-organism infection.
- Unusual agents of chronic mastoiditis include Mycobacterium tuberculosis, nontuberculous mycobacteria, Nocardia asteroides, and Histoplasma capsulatum.
- Cholesteatomas may contribute to the development of mastoiditis by impeding mastoid drainage or erosion of underlying bone.
Diagnosis
History
- May include a recent or a chronic history of treatment for otitis media
- Sign and symptoms
- May include fever, otalgia, otorrhea, and postauricular swelling
- Children who are already on antibiotics may present with more subtle findings.
- Intracranial extension should be suspected if there is lethargy, a stiff neck, headache, focal neurologic symptoms, seizures, visual changes, or persistent fevers despite appropriate antibiotic treatment.
- Labyrinthitis initially presents with tinnitus and nausea, which can progress to vomiting, vertigo, nystagmus, and loss of balance.
Physical Exam
- The ear may protrude away from the scalp:
- In children less than 2 years old, the ear protrudes out and is displaced down. In older children, the ear is displaced up.
- The external ear canal may be edematous or sagging.
- The tympanic membrane often is hyperemic, with decreased mobility, or perforated:
- The tympanic membranes of children on antibiotics may have a normal appearance.
- The mastoid process is tender, with soft tissue swelling:
- The overlying skin may be warm and erythematous, with posterior auricular fluctuance.
- In chronic mastoiditis, the fever and posterior auricular swelling are often not present and the patient presents with ear pain, persistent drainage, or hearing loss.
Diagnostic Tests & Interpretation
Lab
- CBC with differential: nonspecific
- May be normal or show a leukocytosis with a neutrophil predominance
- ESR/CRP
- May be elevated in acute mastoiditis but is usually normal in the chronic stage; more often elevated in complicated mastoiditis
- Purified protein derivative (PPD)
- Should be done if tuberculosis is suspected
- Middle ear aspirate
- Gram stain and cultures for aerobic and anaerobic bacteria
- There is some correlation between middle ear bacterial cultures and mastoid cultures.
- If possible, drainage prior to antibiotic administration is more helpful in making a microbiologic diagnosis.
Imaging
- X-rays
- Reveal haziness of the mastoid air cells and can show bony destruction in more advanced disease
- Are unreliable and can be falsely normal, as well as falsely abnormal
- Contrast-enhanced temporal bone and cranial CT
- Helpful in the confirmation of the diagnosis, identification of coalescence or a subperiosteal abscess, and evaluation for concomitant intracranial complications
- Intracranial complications are best seen with MRI.
Diagnostic Procedures/Other
Lumbar puncture must be performed in any child with symptoms of meningitis.
Differential Diagnosis
- Parotitis
- Posterior auricular lymphadenopathy or cellulitis
- Otitis externa or an ear canal furuncle
- Perichondritis of the auricle
- Neoplastic disease
- Leukemia
- Lymphoma
- Rhabdomyosarcoma
- Langerhans Cell Histiocytosis
- Branchial cleft anomaly
- Tuberculosis
Treatment
Medication
- Parenteral antibiotics are chosen based on the most likely organisms, regional bacterial resistance patterns, and the child 's condition.
- Intravenous antibiotics are given for at least 7 " 10 days followed with oral antibiotics for a total duration of 4 weeks of therapy.
- A third- or fourth-generation cephalosporin such as ceftriaxone or cefotaxime or cefepime is often used with or without vancomycin for empiric treatment.
- Subsequent antibiotic choice should be tailored to antimicrobial sensitivities of the ear aspirate.
- If M. tuberculosis is suspected, then antituberculosis therapy should be started.
Additional Treatment
General Measures
Middle ear drainage is essential; therefore, a myringotomy with or without tube placement should be performed early.
Surgery/Other Procedures
- Indications for surgical intervention include the following:
- Subperiosteal abscess
- Coalescence
- Facial nerve palsy
- Meningitis
- Intracranial abscess
- Venous thrombosis
- Persistent symptoms despite adequate antibiotic treatment
- In the preantibiotic era, mastoidectomy was the treatment of choice for mastoiditis. Currently, this therapy is generally reserved for cases complicated by the aforementioned indications.
- Neurosurgical consultation for treatment of intracranial complications may be necessary.
Inpatient Considerations
Admission Criteria
Admit for IV antibiotics and for ear, nose, and throat (ENT) evaluation for surgical drainage and to ensure response to antibiotics and to rule out complications.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- If patients respond quickly to parenteral therapy, they can complete a 3- to 4-week course with oral antibiotics and weekly follow-up visits.
- Audiograms should be performed later to screen for hearing loss.
Prognosis
- Mastoiditis has a good prognosis if treated early. However, intracranial extension of mastoiditis can lead to permanent neurologic deficits and death.
- Chronic mastoiditis can lead to irreversible hearing loss.
Complications
- The proximity of the mastoid to many important structures can result in serious complications from extension of infection or as a response to the inflammatory process.
- Complication rates may be as high as 16%.
- Intracranial complications include meningitis and extradural, subdural, or brain parenchymal abscesses.
- Venous sinus thrombophlebitis results from extension of disease to the sigmoid or lateral sinus:
- Sepsis, increased intracranial pressure, or septic emboli may result.
- Facial nerve palsy is usually unilateral and can be permanent.
- Labyrinthitis, petrositis, or osteomyelitis may result from extension of the infection into adjacent bones.
- Subperiosteal abscess
- Hearing loss can occur from destruction of the ossicles or from labyrinthine damage.
- Bezold abscess is a deep neck abscess along the medial sternocleidomastoid muscle that develops when the infection erodes through the tip of the mastoid bone and dissects down tissue planes.
- Gradenigo syndrome
- Triad of 6th nerve palsy, retro-orbital pain, and otorrhea
Additional Reading
- Agrawal S, Husein M, MacRae D. Complications of otitis media: an evolving state. J Otolaryngol. 2005;34(Suppl 1):S33 " S39. [View Abstract]
- Anderson K, Adam H. Mastoiditis. Pediatr Rev. 2009;30(6):233 " 234. [View Abstract]
- Bilavsky E, Yarden-Bilavsky H, Samra Z, et al. Clinical, laboratory, and microbiological differences between children with simple or complicated mastoiditis. Int J Pediatr Otorhinolaryngol. 2009;73(9):1270 " 1273. [View Abstract]
- Groth A, Enoksson F, Hultcrantz M, et al. Acute mastoiditis in children aged 0-16 years " a national study of 678 cases in Sweden comparing different age groups. Int J Pediatr Otorhinolaryngol. 2012;76(10):1494 " 1500. [View Abstract]
- Kaplan SL, Mason EO Jr, Wald ER, et al. Pneumococcal mastoiditis in children. Pediatrics. 2000;106(4):695 " 699. [View Abstract]
- Minks DP, Porte M, Jenkins N. Acute mastoiditis " the role of radiology. Clin Radiol. 2013;68(4):397 " 405. [View Abstract]
- Pang LH, Barakate MS, Havas TE. Mastoiditis in a paediatric population: a review of 11 years of experience in management. Int J Pediatr Otorhinolaryngol. 2009;73(11):1520 " 1524. [View Abstract]
- Pritchett CV, Thorne MC. Incidence of pediatric acute mastoiditis: 1997 " 2006. Arch Otolaryngol Head Neck Surg. 2012;138(5):451 " 455. [View Abstract]
- Psarommatis IM, Voudouris C, Douros K, et al. Algorithmic management of pediatric acute mastoiditis. Int J Pediatr Otorhinolaryngol. 2012;76(6):791 " 796. [View Abstract]
- Zanetti D, Nassif N. Indications for surgery in acute mastoiditis and their complications in children. Int J Pediatr Otorhinolaryngol. 2006;70(7):1175 " 1182. [View Abstract]
Codes
ICD09
- 383.9 Unspecified mastoiditis
- 383.00 Acute mastoiditis without complications
- 383.02 Acute mastoiditis with other complications
- 383.1 Chronic mastoiditis
- 383.01 Subperiosteal abscess of mastoid
ICD10
- H70.90 Unspecified mastoiditis, unspecified ear
- H70.009 Acute mastoiditis without complications, unspecified ear
- H70.099 Acute mastoiditis with other complications, unspecified ear
- H70.10 Chronic mastoiditis, unspecified ear
- H70.11 Chronic mastoiditis, right ear
- H70.092 Acute mastoiditis with other complications, left ear
- H70.91 Unspecified mastoiditis, right ear
- H70.013 Subperiosteal abscess of mastoid, bilateral
- H70.13 Chronic mastoiditis, bilateral
- H70.091 Acute mastoiditis with other complications, right ear
- H70.003 Acute mastoiditis without complications, bilateral
- H70.012 Subperiosteal abscess of mastoid, left ear
- H70.093 Acute mastoiditis with other complications, bilateral
- H70.92 Unspecified mastoiditis, left ear
- H70.011 Subperiosteal abscess of mastoid, right ear
- H70.019 Subperiosteal abscess of mastoid, unspecified ear
- H70.002 Acute mastoiditis without complications, left ear
- H70.93 Unspecified mastoiditis, bilateral
- H70.001 Acute mastoiditis without complications, right ear
- H70.12 Chronic mastoiditis, left ear
SNOMED
- 52404001 mastoiditis (disorder)
- 335846001 Acute mastoiditis without complications
- 111538005 Acute mastoiditis with complication
- 80645004 chronic mastoiditis (disorder)
- 72102005 Subperiosteal abscess of mastoid
FAQ
- Q: Do all children with mastoiditis need a CT scan of the head if mastoiditis is suspected?
- A: No. In general, if the child with mastoiditis has mild swelling, no fluctuance of the mastoid, and responds to therapy, no CT scan is needed. A patient who appears toxic or fails to respond to appropriate antibiotic therapy or one who may be a surgical candidate should undergo additional imaging studies.
- Q: Should all children with mastoiditis be admitted to the hospital?
- A: Yes. In general, admission with IV antibiotics and ENT evaluation/drainage is warranted to ensure response to antibiotics and rule out complications.