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Mastoiditis Clinical Presentation

  • Author: PP Devan, MBBS, MS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 04, 2016
 

History

Most patients (>80%) have no history of recurrent otitis media. Persistent otorrhea beyond 3 weeks is the most consistent sign that a process involving the mastoid has evolved.

The patient’s fever may be high and unrelenting in acute mastoiditis, but this may be related to the associated acute otitis media (AOM). Persistence of fever, particularly when the patient is receiving adequate and appropriate antimicrobial agents, is common in acute surgical mastoiditis (ASM).

Pain is localized deep in or behind the ear and is typically worse at night. Persistence of pain is a warning sign of mastoid disease. This may be difficult to evaluate in very young patients. Hearing loss is common with all processes that involve the middle ear cleft.

For infants, be attentive to any nonspecific history consistent with infection, such as poor feeding, fever, irritability, or diarrhea.

In a study by Oestreicher-Kedem et al, the mean interval from onset of illness to mastoiditis was found to be 4.5 days.[9] Ear cultures most often grew S pneumoniae and P aeruginosa (23.7% each). Complications occurred in 15.8% of cases. The only factor differentiating children with and without complications was the white blood cell count (high in children with complications).

The findings in this study indicate that acute mastoiditis is not only a complication of prolonged infection of the middle ear but also may present as an acute infection of the mastoid bone that can progress within 48 hours. The complication rate remains high, and antibiotic treatment at the onset of symptoms does not prevent complications. A high white blood cell count on admission may serve as a predictive factor for complicated cases.

In a study by Niv et al of 113 patients with acute mastoiditis (128 episodes) treated between 1990 and 2002, the authors concluded that (1) a significant increase in the incidence of acute mastoiditis in infants had been recorded, although the reason for the trend was uncertain; (2) in most infants with acute mastoiditis, the disease arose after the infant's initial AOM episode, and most of the infants had not received prior antibiotic therapy; (3) infants showed more severe clinical signs and symptoms of acute mastoiditis than did older patients; (4) S pneumonia was the most common pathogen isolated in middle ear fluid cultures, but there was a greater involvement of S pyogenes in the cases of acute mastoiditis than had been reported for AOM.[10]

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Physical Examination

Acute mastoiditis is a serious bacterial infection of the temporal bone and is the most common complication of otitis media. Frequent symptoms include mastoid area erythema, proptosis of the auricle, and fever.[11]

Tenderness and inflammation over the mastoid process is the most consistent sign of acute surgical mastoiditis (ASM). Periosteal thickening requires comparison to the other side, and some lateral displacement of the auricle may be present. Subperiosteal abscess displaces the auricle laterally and obliterates the postauricular skin crease. If the crease remains, the process is lateral to the periosteum.

Although the diagnosis of acute surgical mastoiditis can often be made on a clinical basis alone, computed tomography (CT) scanning may be performed for confirmation of the diagnosis, evaluation of potential complications, and surgical planning. Also keep in mind that it is possible to have mastoiditis with no history of otitis media, normal external anatomy, no tenderness, and no external signs of infection.

Otitis media is revealed on otoscopy, often with 1 of the following additional features:

  • Sagging of the posterosuperior canal wall (possibly a sign of ASM, although not as reliable in infants)
  • Nipplelike protrusion of the central tympanic membrane, usually oozing pus
  • Findings consistent with a complication of extension beyond the mastoid process and its covering periosteum or another intratemporal complication, such as facial palsy

In adults, the most common symptoms of mastoiditis are otalgia, otorrhea, and hearing loss, and the physical signs of mastoiditis (ie, swelling, erythema, tenderness of the retroauricular region) are usually present. Localization and enlargement of the pathological process within the middle ear spaces can be determined based on CT scan findings.

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Contributor Information and Disclosures
Author

PP Devan, MBBS, MS Professor and Head, Dept of ENT, A J Institute of Medical Sciences, Mangalore, India

Disclosure: Nothing to disclose.

Coauthor(s)

John D Donaldson, MD, FRCSC, FACS Pediatric Otolaryngologist, Chief of Surgery, Galisano Children's Hospital, Lee Memorial Health System

John D Donaldson, MD, FRCSC, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, American Academy of Pediatrics, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

Karin S Chase, MD Assistant Clinical Instructor and Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital

Karin S Chase, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Christopher I Doty, MD, FACEP, FAAEM Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gerard J Gianoli, MD Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Vesticon, Inc. None Board membership

Alyssa K Hamman, MD Research Assistant, Division of Emergency Medicine, Stanford University

Alyssa K Hamman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

N Ewen Wang, MD Consulting Staff, Department of Surgery, Division of Emergency Medicine, Stanford University Hospital

Disclosure: Nothing to disclose.

References
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  7. Marom T, Tan A, Wilkinson GS, et al. Trends in otitis media-related health care use in the United States, 2001-2011. JAMA Pediatr. 2014 Jan. 168(1):68-75. [Medline]. [Full Text].

  8. Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, et al. Acute mastoiditis--the antibiotic era: a multicenter study. Int J Pediatr Otorhinolaryngol. 2001 Jan. 57(1):1-9. [Medline].

  9. Oestreicher-Kedem Y, Raveh E, Kornreich L, Popovtzer A, Buller N, Nageris B. Complications of mastoiditis in children at the onset of a new millennium. Ann Otol Rhinol Laryngol. 2005 Feb. 114(2):147-52. [Medline].

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  13. National Cancer Institute. Radiation Risks and Pediatric Computed Tomography (CT): A Guide for Health Care Providers. National Institutes of Health. Available at http://www.cancer.gov/cancertopics/causes/radiation/radiation-risks-pediatric-CT. Accessed: October 2, 2011.

  14. Saat R, Laulajainen-Hongisto AH, Mahmood G, et al. MR imaging features of acute mastoiditis and their clinical relevance. AJNR Am J Neuroradiol. 2015 Feb. 36 (2):361-7. [Medline].

  15. Enoksson F, Groth A, Hultcrantz M, Stalfors J, Stenfeldt K, Hermansson A. Subperiosteal abscesses in acute mastoiditis in 115 Swedish children. Int J Pediatr Otorhinolaryngol. 2015 Jul. 79 (7):1115-20. [Medline].

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Mastoiditis with subperiosteal abscess. Note the loss of the skin crease and the pointed abscess.
Cortical mastoidectomy in a densely sclerosed mastoid.
Preoperative preparation of the patient.
Draping the surgical area.
Injection of the area with 2% Xylocaine and 1:100,000 adrenaline to reduce bleeding.
Marking the incision site.
Placement of the incision, a few mm behind the postauricular sulcus.
Deepening the incision down to the bone.
Elevation of the periosteum to expose the mastoid cortex to the mastoid tip.
Mastoid drilling in progress with simultaneous saline irrigation.
Creation of the initial groove and the vertical line.
Exposure of the antrum and exenteration of the mastoid air cells.
Curetting the aditus to enlarge it.
Further exposure.
Healed postaural scar.
Extent of cortical mastoidectomy in a well-pneumatized mastoid.
 
 
 
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