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Home | Articles | Ear, Nose and Throat | Acute Mastoiditis

Acute Mastoiditis

Last updated 10th October 2023

Definition

  1. Acute mastoiditis refers to infection of the mastoid air cells in the temporal bone and can occur at any age. It is a very rare condition.

Pathophysiology

  1. The mastoid is part of the petrous temporal bone and is located posterior to the middle ear.
  2. Mastoiditis is associated with the progression of AOM with infection spreading from the middle ear into the mastoid air cell system via the mastoid antrum, causing osteitis of mastoid bone.
  3. Initially, there is hyperaemia and oedema of the mastoid air cell mucosa. Mucositis and swelling of the aditus ad antrum block effective drainage of the mastoid air cell system. Serous then purulent exudate collects in the air cells.
  4. Increased pressure within the air cell system results in bone necrosis of the thin bony septae. Pus coalesces and an abscess cavity form.

History

Typical symptoms of mastoiditis in children (<2) include

  1. Ear pulling
  2. Ear pain
  3. Non-specific symptoms of systemic upset: irritability, fever, lethargy, reduced oral intake, diarrhoea
  4. Persistent fever despite appropriate oral antibiotics

Typical symptoms of mastoiditis in adults include

  1. Severe otalgia
  2. Otorrhoea
  3. Headache
  4. Hearing loss
  5. Persistent fever despite appropriate oral antibiotics
  6. Vertigo

Key Diagnostic Criteria

  1. Tenderness of the mastoid can be normal with uncomplicated ear infections such as otitis externa: mastoiditis patients are systemically very unwell.
  2. Patients with mastoiditis are septic: pyrexial, anorexic and lethargic. Children will be irritable and will not feed.
  3. Patients will have signs and symptoms of an underlying ear infection eg red, bulging tympanic membrane or purulent ear discharge.
  4. The sharp angle between the ear and the mastoid, the auriculomastoid sulcus, is lost: compare with the contralateral ear.
  5. As the disease progresses, the pinna is classically pushed downwards and forwards with boggy oedema of the mastoid: compare with the contralateral ear.
 
B. Welleschik, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons

Treatment

  1. If acute mastoiditis present – Urgent referral to ENT
  2. See below for initial management:

    Is it acute mastoiditis ± periostitis/osteitis?


    Symptoms - Otalgia / headache / fever
    Signs
    1. Protrusion of the pinna, loss of post-aurticular sulcus (95-100%)
    2. Post-auricular swelling (80-95%), erythema, mass or fluctuance
    3. Otoscopy (uni or bilateral findings) - Posterior/superior canal swelling ± bulging / erythematous tympanic membrane ± purulent. discharge (30%) or normal otoscopy
    4. Pyrexia (81%); less common if antibiotics

    Admit + Baseline Investigations


    1. FBC, U&E, CRP
    2. Blood cultures (if pyrexia)
    3. Ear swab if discharge present

    Discharge (all criteria to be met)


    1. Swelling has resolved
    2. No signs of complications
    3. Pyrexia settled, eating and drinking, no parental concerns and patient established on oral antibiotics

    Medical Management


    1. IV Ceftriaxone OD + IV Metronidazole TDS (or as per local guidelines) if penicillin allergy discuss with Microbiology
    2. Microbiology advice for antibiotic sensitivities/if deteriorating/treatment duration/de-esclation from IV to PO therapy
    3. Consider topical treatment e.g. topical ear antibiotic drops e.g. Ciprofloxacin 2 drops TDS
    4. 4 hourly vital signs and review by nursing staff and regular observations by the medical team

Links

  1. Geeky Medics – Mastoiditis
  2. Entsho – Complications of Otitis Media
  3. British Society of Otology – Acute Mastoiditis Guidelines

Content by Alexandra Barabas and Marissa Botma