Mastoiditis Treatment & Management
- Author: PP Devan, MBBS, MS; Chief Editor: Arlen D Meyers, MD, MBA more...
Surgical therapy confined to the ear includes myringotomy/tympanocentesis, tympanostomy tube placement, and mastoidectomy. In the preantimicrobial era, mastoidectomy was performed in as many as 20% of patients with acute otitis media (AOM). By 1948, this figure had dropped to less than 3%, and it is presently thought to be performed in fewer than 5 cases per 100,000 persons with AOM. (See the images below.)
Indications for the simple mastoid operation include cases of acute suppurative otitis media that fail to respond to appropriate antibiotic therapy and progress to coalescent mastoiditis. Incidence of mastoiditis and, thus, mastoidectomy should decline further with the availability and administration of conjugated pneumococcal vaccine.
When considering surgery, the risks of exposure to general anesthesia must be weighed against the risk of complications and progression of the infection. Contraindications to surgery include a low hemoglobin concentration and general systemic illness that must be controlled (eg, diabetes, hypertension, poor cardiac condition, bleeding disorders with prolonged bleeding and clotting time).
Acute mastoiditis without osteitis or periosteitis
This is the only mastoid condition treated purely with medical management. Standard antibiotic therapy is administered for AOM, and resolution is anticipated within 2 weeks.
If complications occur (pain and fever persist beyond 48 h or tenderness increases), obtain cultures via the middle ear, commence new antimicrobial therapy, and obtain imaging of the mastoid. Consider mastoidectomy if symptoms persist or if the new antibiotics fail.
Acute mastoiditis with osteitis
This is a surgically treated disease, although coverage with appropriate antibiotics is mandatory. Mastoidectomy with insertion of a tympanostomy tube is required to remove areas of coalescence within the temporal bone.
This author uses single-, high-dose systemic steroids preoperatively or intraoperatively to control swelling, nausea, and inflammation without negatively impacting the child’s immunological response.
Antibiotic selection should provide good intracranial penetration and MDRSP coverage. With the high frequency of invasive resistant strains in mastoiditis, initial therapy of intravenous vancomycin and ceftriaxone is most appropriate until results of the culture and sensitivity studies are available.
Postoperatively, antibiotic/steroid drops are used to keep the tube patent and to reduce middle ear swelling.
Patients with spread of empyema beyond the mastoid require drainage of the abscess and mastoidectomy. Intracranial spread requires a combined neurosurgical and otolaryngological approach.
Acute mastoiditis with periosteitis
Postauricular swelling and erythema without subperiosteal abscess or mastoid osteitis can be treated more conservatively, using parenteral antibiotics, high-dose steroids, and tympanostomy tube insertion. Vancomycin and ceftriaxone are recommended until cultures become available. Again, systemic steroids slow the inflammation and promote drainage.
If substantial resolution of pain, fever, and erythema does not occur within 36-48 hours after institution of therapy, mastoidectomy is warranted.
If transfer is required, it invariably relates to the availability of subspecialists, most notably pediatric otolaryngologists or otologists, pediatric neurosurgeons, or pediatric critical care specialists. Available radiographs should be copied and should accompany the patient, along with any available laboratory data. Instruct patients to take nothing by mouth until the receiving subspecialists evaluate their conditions.
When transfer is not possible, occasional operators (particularly in children) should be aware that it is more important to establish wide communication between mastoid cavity and middle ear than to open all the air cells of the mastoid. Almost always, opening the antrum and leaving an external drain will suffice.
Early consultation with an otolaryngologist is appropriate and necessary if the pediatrician is not comfortable performing tympanocentesis. If cultures indicate the presence of resistant or unusual microbes, consultation with appropriate infectious-disease specialists may be required. Consultation with a neurosurgeon is appropriate if evidence of intracranial extension with abscess formation exists.
Monitor the patient's temperature; it usually falls dramatically within the first 24 hours, after which the patient can be allowed up. After obtaining cultures (either by tympanocentesis or during tympanostomy tube placement, with or without mastoidectomy), continue initial antibiotic selection until cultures are reported. If the patient becomes afebrile and if swelling decreases at 48-72 hours, oral medication may be selected based on culture reports.
Children who have had a mastoidectomy are released from the hospital after the discharge from the surgically implanted drain abates. The drain is normally removed 48-72 hours postoperatively.
Antibiotic/steroid drops are continued until the otorrhea ceases and the tympanostomy tube is noted to be open with healing or healed mucosa behind.
Antibiotics are the principal medications used in acute surgical mastoiditis (ASM). Culture results and the sensitivity of the organism ultimately govern selection of medications. Until microbiology information is available, the following principles guide the selection: (1) the antimicrobial must be appropriate to cover the invasive strains of bacteria most common for AOM, (2) the selected antibiotic should cross the blood-brain barrier, and (3) the selected therapeutic spectrum should include consideration of MDRSP organisms that are prevalent in the individual’s community. Specific microbiologic diagnoses should be treated with appropriate antibiotics.
If open mastoid surgery is not undertaken, use of single, high-dose, intravenous steroids is warranted to decrease mucosal swelling and to promote natural drainage through the aditus ad antrum into the middle ear.
Other medications used include analgesics, antipyretics, and topical antibiotic/steroid combinations. After placement of a tympanostomy tube, with or without mastoidectomy, a pH-balanced solution or suspension of an antibiotic and steroid is useful to decrease mucosal swelling and to deliver topical antibiotics to the middle ear and mastoid. Continue the drops until otorrhea ceases and the view through the tube shows healing mucosa without swelling or obstruction. Multiple combinations are available, the best being those thin enough to rub through the tube into the middle ear.
Myringotomy/Tympanocentesis and Tympanostomy Tube Placement
Myringotomy/tympanocentesis is primarily used to obtain specimens and to relieve discomfort from acute otitis media (AOM). These openings usually heal within a few days.
A tympanostomy tube allows for drainage of entrapped pus and aeration of the middle ear and mastoid. It may sometimes allow topical antimicrobials to enter the middle ear space. Because it is used as a drain, a tympanostomy tube is usually placed during mastoidectomy.
A tube maintains the opening in the tympanic membrane and provides access to the middle ear and mastoid for antibiotic/steroid drops and for drainage without concern for patency of the Eustachian tube. Ear drops containing only antibiotics are less effective than those containing a steroid to control swelling.
A retrospective study by Enoksson et al indicated that in pediatric patients with subperiosteal abscess caused by acute mastoiditis, retroauricular needle aspiration and/or incision, used in combination with intravenous antibiotics and myringotomy, is an effective first-line treatment for the abscess. The study compared outcomes in 33 children who underwent this therapy with those of 67 children who underwent mastoidectomy, with few significant differences found between the two groups (although members of the mastoidectomy group tended to have longer hospital stays).
Mastoidectomy is surgical removal of infected mastoid air cells. This procedure involves opening the mastoid air cells by making a postauricular incision and entering the mastoid by removing the mastoid cortex using a drill. Often, children will have thinned out cortex with pus coming through the residual bone and the mastoid can be entered easily and safely using a mastoid curette rather than a drill. Any subperiosteal abscess is opened during this time. Upon entering the mastoid, the surgeon most often encounters granulation tissue and swollen polypoid mucosa that block the aditus ad antrum. Most of the diseased air cells are opened, and access to the middle ear is gained by removing the blockage at the antrum. After irrigating the ear, a drain is inserted through the wound, where it is left for at least 2 days.
With a simple (or closed) mastoidectomy, the surgeon either makes an incision behind the ear to access the mastoid region or removes the infected air cells by approaching through the ear. Radical mastoidectomy, involves removal of the tympanic membrane, most middle ear structures, and closing the eustachian tube opening. Modified radical mastoidectomy preserves the ossicles and tympanic membrane remnants.
Mastoidectomy is indicated in cases of advanced disease, such as mastoid osteitis, intracranial extension, abscess formation, when cholesteatoma is involved, or if little improvement occurs after 24-48 hours of intravenous antibiotics.
Preoperative preparation entails shaving the area behind the involved side (in the postaural area) a width of 3 fingers to avoid wound contamination. (See the images below.)
A postaural incision is placed a few millimeters from the postaural sulcus. In infants, the incision is placed higher and more horizontally because the mastoid process is not developed and the facial nerve is more superficial. (See the image below.)
The incision is deepened through the periosteum to the bone. At this stage, a subperiosteal abscess will discharge pus. Care must be taken in the upper half of the incision. The lower border of the temporalis muscle should be identified and conserved. If incising it to obtain adequate exposure is necessary, the vessels running at its lower border are first ligated or diathermied. (See the image below.)
The periosteum is lifted from the underlying bone with periosteal elevators to expose the spine of Henle, the Macewen triangle, and the posterior bony margin of the meatus. In older children and adults, the tendon of the sternomastoid muscle has a wide attachment to the superficial aspect of the mastoid process; the fibers are scraped off with a periosteal elevator. (See the image below.)
The periosteum is elevated forward as far as the lateral end of the posterior bony meatal wall, backward for a few millimeters, and upward (simultaneously pushing up the temporalis muscle) to the level of the upper attachment of the pinna. A Mollison self-retaining hemostatic mastoid retractor is inserted to hold the soft tissues away from the underlying exposed bone.
The surgeon should use known visible landmarks to find the deeper landmarks. Drilling is commenced posterior to the posterior canal wall in a vertical direction. A triangle-shaped excavation is created, with the superior limit bounded by the extension of the linea temporalis (which becomes the floor of the middle fossa as one drills deeper), the posterior margin bounded by the sigmoid sinus, and the anterior margin bounded by the thinned wall of the posterior external ear canal. (See the images below.)
The mastoid cortex is now removed over the Macewen triangle (which is a rough guide to the position of the underlying mastoid antrum) using a drill fitted with a large cutting burr (5-6 mm). In adults, the antrum is encountered at a depth of 15-17 mm. If there is a deviation in the direction of drilling, the approach to the antrum can be seriously misaligned.
An ideal method to gauge the antrum is to insert an angled cell seeker beyond the posterosuperior bony meatal wall (which will be the site of the antrum) and then to drill toward it.
The antrum is usually apparent when opened by the drill. It can be confirmed by gentle anterior probing with a Dundas-Grant probe, which will slip into the aditus. Exercise care to avoid dislodging the short process of the incus. Simultaneously, the size of the aditus should be judged. If it is very small, it may be enlarged slightly with a fine bone curette to ensure adequate drainage of the middle ear.
The antral exposure is enlarged, opening adjacent cells until the lateral semicircular canal (the important landmark at this stage) can be identified. The position of middle and posterior fossa dura and the sigmoid sinus plate must be judged from the lateral oblique radiograph of the mastoid. Next, all cells in all directions are opened by drilling gently through their separating trabecula. Clearing all cells from the sinodural angle is particularly important. The smooth plate of bone covering the middle fossa dura above and lateral sinus posteriorly is recognized easily. (See the images below.)
If the region is filled with necrotic mucosa, it may be safer to scoop out the material with a curette, always sweeping from the vertical position of the facial nerve as it descends just below the back of the lateral semicircular canal. Cells along the vertical portion of the facial nerve are best removed under microscope visualization with a diamond burr.
In a well-pneumatized skull, cells may extend anteriorly into the root of the zygoma and posteriorly into the occipital bone. These must also be followed as far as practicable. Consequent to mastoid clearance, a cavity is created with the antrum at the deepest point. The cavity is bounded above by the bony tegmen separating the region from the dura of the middle cranial fossa, behind by the bony plate over the sigmoid sinus, and in front by the posterior meatal wall and the aditus ad antrum.
In front of the bulge of the sigmoid sinus plate, cell removal uncovers the bone of the Trautman triangular space, protecting the dura of the posterior canal fossa and leading to the solid angle where the dense bone of the otic capsule protects the posterior semicircular canal. Anteriorly and much more superficially, cells should be opened as far as they extend into the root of the zygoma. Inferiorly, cell pursuit leads to the bone covering the digastric muscle as it passes forward, deep to the inferior part of the facial nerve at the stylomastoid foramen.
When cortical mastoidectomy is performed for proved suppurative mastoiditis, the bone over the sigmoid sinus should be sufficiently removed to allow insertion of a fine needle into that vessel to confirm that no thrombophlebitis exists within.
Closure of the wound is with interrupted sutures, and most otologists leave a soft drain in the lower part of the cavity for 1-2 days. A firm pressure dressing controls the bleeding. (See the image below.)
Although facial nerve monitoring is a useful adjunct, nothing substitutes for experience and attention to detail when preserving the facial nerve. Experienced otologists are unlikely to injure the ossicular chain during mastoid surgery.
Care must be taken to avoid damage to the ossicular chain. Persistent conductive hearing loss caused by tympanosclerotic plaques formed from residual bone dust can be avoided with copious irrigation at the end of the surgery.
Complications associated with mastoidectomy
Although mastoidectomy is a common surgical procedure in otology, postoperative complications of various degrees of severity may occur. Such complications include the following:
Injury to the facial nerve
Dislocation of the incus
Penetration of the middle or posterior fossa
Rupture of the sigmoid sinus
Labyrinthine transgression and destruction
Persistent deafness may be due to incus dislocation or removal. The ear dries, and the tympanic membrane heals; however, conductive deafness persists. Impedance audiometry indicates disruption of the ossicular chain. Anterior tympanotomy and reconstruction of the ossicular chain may be performed.
Persistent deafness may also be caused by persistent infection due to residual cells. Infection should resolve with proper medical treatment and good drainage. If infection persists, reopening of the mastoid and exenteration of the remaining cells is required.
If complete facial nerve paralysis is present immediately postoperatively, the facial nerve has been damaged intraoperatively. The mastoid must be reopened, and the vertical part of the nerve must be explored and, if necessary, grafted.
Meatal stenosis may ensue if the bony meatal wall has been taken down and if the skin has been dissected off the bony wall. Meatal stenosis requires excision of the stenosed area and firm packing of the canal until reepithelization occurs.
Complications reported have included brain abscess 1 week after mastoidectomy in a child and, in another child, seizures 5 days after the initial mastoidectomy and a subdural empyema that was drained during the revision surgery. Large bone defects with exposed middle cranial fossa dura were found during revision surgery in both patients, and Proteus vulgaris and methicillin-resistant S aureus were isolated from the mastoid and abscess cavities in these children.
A small epidural collection was diagnosed 2 days after initial mastoid surgery and was managed with intravenous antibiotics only.
In another reported case, sigmoid sinus thrombosis developed the day after mastoidectomy was performed for nonresponsive acute mastoiditis. This child received both intravenous antibiotics and anticoagulants. Timely revision surgery, combinations of third- or fourth-generation cephalosporins with vancomycin or metronidazole, and the addition of anticoagulants in cases of sinus thrombosis can lead to full recovery.
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