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Mastoiditis Workup

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

Approach Considerations

Despite the use of antibiotics, acute mastoiditis still remains a threat for patients with acute otitis media (AOM), especially for children younger than age 5 years. Great care is required on the part of clinicians to make an early diagnosis in order to promote adequate treatment and to prevent complications.[11]

Material for culture and sensitivity should be obtained from the ear (via tympanocentesis or myringotomy), blood, any abscess, and mastoid tissue (if it becomes available). Obtain and evaluate spinal fluid if any suggestion exists of intracranial extension of the process.

Complete blood count

A complete blood count (CBC) and sedimentation rate are obtained for baseline studies used to evaluate the efficacy of therapy. A high white blood cell count on admission may serve as a predictive factor for complicated cases.

Audiometry

In the light of the prevailing medicolegal climate, an audiometric evaluation must be obtained. Audiometry is seldom appropriate or useful for children with ASM, but it must be performed after convalescence from the acute phase and with children who have chronic mastoiditis. In the at-risk population (children < 2 y), thresholds for air and bone conduction under headphones are only rarely obtained.

Tympanocentesis/myringotomy

Tympanocentesis is a puncture of the tympanic membrane for aspiration of middle ear fluid. The tympanic membrane typically heals within several days. Send fluid for cultures, Gram stain, and acid-fast stain. It is often possible in an acute infection to convert a tympanocentesis into a myringotomy without undue discomfort by widening the needle hole with alligator forceps.

Myringotomy is a small incision of the tympanum to express fluid from the middle ear in chronic or recurrent otitis media; it often relieves discomfort associated with pressure from acute otitis media (AOM). Tympanostomy tube insertion is also performed in most cases to allow for continued drainage and so that administered therapeutic otic drops reach the middle ear.

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Imaging Studies

CT scanning

CT scanning of the temporal bone is the standard for evaluation of mastoiditis, with published sensitivities ranging from 87-100%. Some argue that all suspected cases of mastoiditis warrant CT scan evaluation.[12]

The following findings are used to differentiate acute otitis media (AOM)/acute mastoiditis without osteitis, acute surgical mastoiditis (ASM), and chronic mastoiditis:

  • Opacification of the mastoid air cells and middle ear by inflammatory swelling of mucosa and by collection of fluid
  • Loss of sharpness or visibility of mastoid cell walls due to demineralization, atrophy, or necrosis of bony septa
  • Haziness or distortion of the mastoid outline, possibly with visible defects of the tegmen or mastoid cortex
  • Enhancement of areas of abscess formation
  • Elevation of the periosteum of the mastoid process or posterior cranial fossa
  • Osteoblastic activity in chronic mastoiditis

It is this author’s belief that in the presence of clear clinical indications of acute surgical mastoiditis, CT scanning may be omitted prior to surgical intervention, avoiding unnecessary radiation exposure as recommended by the US National Institutes of Health.[13]

MRI

Magnetic resonance imaging (MRI) is not typically the radiographic study of choice; however, it is helpful in showing inflammatory processes and differentiating certain tumors. Do not use MRI as a method of evaluating the mastoid, although it is the standard for evaluation of contiguous soft tissue, particularly the intracranial structures. However, MRI is the preferred imaging modality for the potential complications of ASM (ie, abscess formation, sinus thrombosis).

A retrospective study by Saat et al found differences in the MRI characteristics of acute mastoiditis in children, compared with adults. The study, which included 10 children and 21 adults with acute mastoiditis, reported that in the pediatric patients, the prevalences of total opacification of the tympanic cavity and mastoid air cells, intense intramastoid enhancement, destruction of outer cortical bone, subperiosteal abscess, and enhancement of perimastoid meninges were significantly higher than in adults.[14]

A study by Singh et al, however, found that incidental opacification of the mastoid is frequently seen in children, indicating that the diagnosis of pediatric mastoiditis should not hinge on radiologic reports of fluid or mucosal thickening in the mastoid air cells. The study included 515 children who underwent brain MRI for indications not involving mastoiditis or otitis media, with mastoid opacification found in 110 (21.4%) of these patients. Opacification rates in children younger than 1 year and those between ages 1 and 2 years reached 41.7% and 47.5%, respectively.[18]

Plain radiography

In areas of the world where CT scanning is not immediately available, plain radiographs of the mastoids demonstrate clouding of the air cells with bone destruction in ASM. In the vast majority of cases, radiographs suffice to establish the diagnosis but lack the sensitivity to differentiate the stages of the disease and fail to show the petrous apex in any great detail.

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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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  5. Palma S, Bovo R, Benatti A, Aimoni C, Rosignoli M, Libanore M, et al. Mastoiditis in adults: a 19-year retrospective study. Eur Arch Otorhinolaryngol. 2013 Apr 16. [Medline].

  6. Halgrimson WR, Chan KH, Abzug MJ, et al. Incidence of acute mastoiditis in Colorado children in the pneumococcal conjugate vaccine era. Pediatr Infect Dis J. 2014 May. 33(5):453-7. [Medline].

  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].

  10. Niv A, Nash M, Slovik Y, Fliss DM, Kaplan D, Leibovitz E, et al. Acute mastoiditis in infancy: the Soroka experience: 1990-2000. Int J Pediatr Otorhinolaryngol. 2004 Nov. 68(11):1435-9. [Medline].

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  12. Vazquez E, Castellote A, Piqueras J, Mauleon S, Creixell S, Pumarola F, et al. Imaging of complications of acute mastoiditis in children. Radiographics. 2003 Mar-Apr. 23(2):359-72. [Medline].

  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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  19. Adams DJ, Susi A, Erdie-Lalena CR, et al. Otitis Media and Related Complications Among Children with Autism Spectrum Disorders. J Autism Dev Disord. 2016 May. 46 (5):1636-42. [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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