eMedicine Specialties > Emergency Medicine > Infectious Diseases

Mastoiditis

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
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

Updated: Sep 28, 2009

Introduction

Background

Mastoiditis is any inflammatory process of the mastoid air cells or posterior process of the temporal bone. 

Acute mastoiditis, also known as classic mastoiditis, is a rare complication of acute otitis media (AOM). Antibiotic treatment of acute otitis media is believed to have decreased the incidence of acute mastoiditis. Chronic mastoiditis, a more latent and sometimes clinically silent version of mastoiditis, is most commonly associated with chronic suppurative otitis media or with cholesteatoma formations. Cholesteatomas are benign tumors of squamous epithelium that can grow and alter normal structure and function of surrounding soft tissue and bone.

Pathophysiology

The mastoid bone develops from an out-pouching of the posterior epitympanum, a part of the temporal bone behind the ear. Pneumatization of the mastoid bone begins shortly after birth and is complete by approximately age 10 years. These air cells are lined with respiratory epithelium. When infection spreads to this area, a blockage of the antrum by inflamed mucosa prevents drainage of fluid. Mucopurulent build up increases air cell pressure, initiates demineralization of cell walls, and potentiates abscess formation and the possibility of extension to surrounding structures: posterior cranial fossa, middle ear fossa, canal of the facial nerve, sigmoid sinus, lateral sinus, petrous tip of the temporal bone.

Frequency

United States

The incidence of mastoiditis from acute otitis media (AOM) is 0.004%. Prior to the 1980s, the reported incidence was 0.4%. Although the incidence of acute mastoiditis decreased dramatically with the introduction of antibiotic treatment, due to contradictory publications, whether the recent incidence is increasing or decreasing is unclear.

Incidence of mastoiditis from acute otitis media is reported as 0.004% in the United States.¹ Some fear that untreated otitis media increases the risk of acute mastoiditis and is the cause of higher incidences in developing countries. Rates of antibiotic treatment for otitis in the Netherlands, Norway, and Denmark were 31%, 67%, and 76%, respectively. The incidence of mastoiditis was approximately 4 cases per 100,000 children per year over 5 years. In Canada and the United States, prescription of antibiotics for otitis is greater than 96%, and the incidence was 2 cases of mastoiditis per 100,000 children per year.²

Mortality/Morbidity

Mastoiditis is a clinically significant infection with the potential of life-threatening complications. Common complications include hearing loss and extension of the infectious process beyond the mastoid system. If the spread of suppuration is anterior to the middle ear via the aditus ad antrum, often spontaneous resolution occurs. However, if the spread of infection is to the intracranial region, deadly and devastating consequences develop.

Race

The Inuit population has a high predilection for middle-ear disease and, as a likely consequence, mastoiditis.

Sex

Mastoiditis occurs equally in females and males.

Age

Acute mastoiditis affects mostly young children and peaks in those aged 6-13 months.

Clinical

History

• Recent or recurrent acute otitis media
• Otalgia
• Hearing loss
• Pain in the mastoid area
• For infants, include any nonspecific history consistent with infection such as poor feeding, fever, irritability, or diarrhea.

Physical

• Persistent or recurrent fever
• Erythematous, bulging tympanic membrane
• Erythema, swelling, or tenderness in the mastoid area
• Protrusion or displacement of the auricle

Although mastoiditis is a clinical diagnosis, it is possible to have disease with no history of otitis media, normal external anatomy, no tenderness, and no external signs of infection.
 
In advanced disease, various symptoms and physical findings will be consistent with the area of extension.

Causes

The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. For example, Haemophilus influenzae, a common cause of otitis media, is isolated much less often in mastoiditis. Gram-negative organisms are found to be the cause of many aggressive cases of mastoiditis. Pseudomonas and Staphylococcus aureus are more commonly isolated in cases of chronic mastoiditis. In general, the prevalence of organisms causing mastoiditis varies greatly between studies, among countries, and according to the age of the patient. 

One recent study out of Houston found that, since the introduction of the 7 valent pneumococcal conjugate vaccine in 2000, the predominant serotype of pneumococcal mastoiditis was the 19A serotype. They also found that this serotype was associated with a more complicated disease course including the increased need for surgical intervention and a greater resistance to antibiotics.³

Reported pathogens are as follows:

• Streptococcus pneumoniae – Most frequently isolated pathogen in acute mastoiditis, prevalence of approximately 25%
• Group A beta-hemolytic streptococci
• Staphylococcus aureus
• Streptococcus pyogenes
• Moraxella catarrhalis
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Mycobacterium species
• Aspergillus fumigatus and other fungi
• Nocardia asteroides - Recent case report⁴

Differential Diagnoses

Workup

Laboratory Studies

Laboratory studies for mastoiditis include the following:

• CBC with differential
• Blood cultures
• Myringotomy/tympanocentesis: Send fluid for cultures, Gram stain, and acid-fast stain.
• If the tympanic membrane spontaneously ruptures, fluid from the middle ear should also be sent for cultures, Gram stain, and acid-fast stain.

Imaging Studies

• Plain radiographs may show increased opacification in the mastoid region; radiography is not a reliable study for evaluation of mastoiditis.
• CT scan may show fluid collection in the middle ear and mastoid region, abscess formations, or demineralization of the mastoid trabeculae. Some argue that all suspected cases of mastoiditis warrant CT evaluation. CT scan is considered a reliable evaluation of mastoiditis with published sensitivities that range from 87-100%.⁵
• MRI may be useful for detailed evaluation of contiguous soft tissue, vascular structures, extra-axial fluid collections, differentiation of tumors, and inflammatory processes. However, MRI is not as applicable as CT in the ED setting.

Other Tests

• Audiography should be performed during and after treatment of mastoiditis to assess for hearing loss. This is not applicable in the ED setting.

Procedures

• Mastoidectomy is surgical removal of infected mastoid air cells. Several different types of mastoidectomy procedures are available. 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.
• 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.
• Tympanocentesis is a puncture of the tympanic membrane for aspiration of middle ear fluid, sometimes performed in the ED setting. The tympanic membrane typically heals within several days.
• Lumbar puncture should be performed if any suspicion exists of intracranial extension of the infection.

Treatment

Emergency Department Care

• Resuscitate the patient as needed. 
• Laboratory and radiologic evaluation for confirmation of suspected diagnosis, evaluation of extent of disease, and for identification of causative organism is warranted. 
• In cases of acute mastoiditis, the patient should be admitted to the hospital. 
• Intravenous antibiotics are indicated for 24-48 hours.

Consultations

• Early ear, nose, and throat (ENT) consultation is essential for further evaluation and to perform surgical intervention if necessary.
• Infectious disease consultation should be considered in cases of rare causative pathogens, if the patient is not responsive to standard treatment, or if one suspects chronic mastoiditis.

Medication

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Antibiotics

These agents should cover the empiric organisms that cause mastoiditis. A third-generation cephalosporin or the combination of a penicillinase-resistant penicillin and an aminoglycoside is recommended. If a patient is allergic to penicillin (history of anaphylaxis), clindamycin can be considered instead of penicillins. If Pseudomonas species is suspected, an antipseudomonal penicillin should be used.

After identification of the organism, antibiotic coverage can be narrowed. Patients should be afebrile for 48 hours before intravenous antibiotics are discontinued. Oral antibiotics should then be administered for an additional 14 days.

Ceftriaxone (Rocephin)

Effective against organisms implicated in mastoiditis. Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.

Dosing

Adult

1-2 g IV q12-24h

Pediatric

50-75 mg/kg IV q24h

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and those allergic to penicillin; not to be given in conjunction with calcium-containing products

Oxacillin (Bactocill)

Bactericidal antibiotic that inhibits cell wall synthesis, used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected. Should be used in combination with an aminoglycoside.

Dosing

Adult

1-2 g IV q4h

Pediatric

200 mg/kg/24h IV divided q6h

Interactions

Decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid, may increase oxacillin levels; effects of anticoagulants increase when large IV doses of oxacillin administered

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function

Gentamicin (Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Should be used in conjunction with a penicillinase-resistant penicillin.

Dosing

Adult

5-7.5 mg/kg/24 h IV divided q8h; adjust dosage in renal impairment

Pediatric

Administer as in adults

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d
600-1200 mg/d IV/IM divided q6-8h depending on degree of infection

Pediatric

8-20 mg/kg/d PO as hydrochloride or 8-25 mg/kg/d as palmitate divided tid/qid
20-40 mg/kg/d IV/IM divided tid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Piperacillin and tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Dosing

Adult

3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Antipyretics

These agents are used for patient comfort.

Acetaminophen (Tylenol)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs and in patients diagnosed with upper GI disease or who are taking oral anticoagulants.
Reduces fever by direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.

Dosing

Adult

500-1000 mg PO q4-6h; not to exceed 4 g/d

Pediatric

15 mg/kg PO q4h; not to exceed 2.6 g/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in individuals with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Follow-up

Further Inpatient Care

• Myringotomy with tympanostomy tube insertion may be performed. 
• 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.  

Further Outpatient Care

• Two weeks of oral antibiotics with the same spectrum of coverage as the intravenous antibiotics should be taken after discontinuation of intravenous antibiotics. 
• The patient should follow up with an ear, nose, and throat (ENT) specialist as well as have an audiogram performed to assess hearing function.

Deterrence/Prevention

• Physicians should be aware of the signs and symptoms of mastoiditis and the complications related to this disease. Patients with chronic otitis media should be referred to an ENT specialist for evaluation.

Complications

Complications of mastoiditis include the following:

• Hearing loss
• Facial nerve palsy
• Cranial nerve involvement
• Osteomyelitis
• Petrositis
• Abscess formation – Bezold's abscess (abscess of soft tissues that track along the sternomastoid sheath), Citelli abscess (extension to occipital bone, calvarium), subperiosteal abscess (abscess between the periosteum and mastoid bone, resulting in the typical appearance of a protruding ear)

Mastoiditis with subperiosteal abscess. Note the loss of the skin crease and the pointed abscess.

• Labyrinthitis
• Gradenigo syndrome – Otitis media, retro-orbital pain, and abducens palsy
• Intracranial extension – Meningitis, cerebral abscess, epidural abscess, subdural empyema
• Sigmoid sinus thrombosis

Prognosis

• If no complications occur, the patient should expect a full recovery.

Miscellaneous

Medicolegal Pitfalls

• Medicolegal pitfalls include failure to diagnose, failure to treat, and failure to detect complications.

Multimedia

Media file 1: Mastoiditis with subperiosteal abscess. Note the loss of the skin crease and the pointed abscess.

References

1. Nussinovitch M, Yoeli R, Elishkevitz K, Varsano I. Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr (Phila). Apr 2004;43(3):261-7. [Medline].

2. Van Zuijlen DA, Schilder AG, Van Balen FA, Hoes AW. National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media?. Pediatr Infect Dis J. Feb 2001;20(2):140-4. [Medline].

3. Ongkasuwan J, Valdez TA, Hulten KG, Mason EO Jr, Kaplan SL. Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates. Pediatrics. Jul 2008;122(1):34-9. [Medline].

4. Casula S, Castro JG, Espinoza LA. An unusual cause of mastoiditis that evolved into multiple ring-enhancing intracerebral lesions in a person with HIV infection. AIDS Read. Aug 2007;17(8):402-4. [Medline].

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

6. Antonelli PJ, Dhanani N, Giannoni CM, et al. Impact of resistant pneumococcus on rates of acute mastoiditis. Otolaryngol Head Neck Surg. Sep 1999;121(3):190-4. [Medline].

7. Bahadori RS, Schwartz RH, Ziai M. Acute mastoiditis in children: an increase in frequency in Northern Virginia. Pediatr Infect Dis J. Mar 2000;19(3):212-5. [Medline].

8. Butbul-Aviel Y, Miron D, Halevy R, Koren A, Sakran W. Acute mastoiditis in children: Pseudomonas aeruginosa as a leading pathogen. Int J Pediatr Otorhinolaryngol. Mar 2003;67(3):277-81. [Medline].

9. Gliklich RE, Eavey RD, Iannuzzi RA, et al. A contemporary analysis of acute mastoiditis. Arch Otolaryngol Head Neck Surg. Feb 1996;122(2):135-9. [Medline].

10. Katz A, Leibovitz E, Greenberg D, et al. Acute mastoiditis in Southern Israel: a twelve year retrospective study (1990 through 2001). Pediatr Infect Dis J. Oct 2003;22(10):878-82. [Medline].

11. Klein JO. Mastoiditis. In: Mandell: Principles and Practice of Infectious Diseases. 5^th ed. Churchill Livingstone; 2000:674-675.

12. Kvestad E, Kvaerner KJ, Mair IW. Acute mastoiditis: predictors for surgery. Int J Pediatr Otorhinolaryngol. Apr 15 2000;52(2):149-55. [Medline].

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

14. 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. Feb 2005;114(2):147-52. [Medline].

15. Taylor MF, Berkowitz RG. Indications for mastoidectomy in acute mastoiditis in children. Ann Otol Rhinol Laryngol. Jan 2004;113(1):69-72. [Medline].

16. Wang NE, Burg JM. Mastoiditis: a case-based review. Pediatr Emerg Care. Aug 1998;14(4):290-2. [Medline].

Keywords

mastoiditis, acute otitis media, chronic mastoiditis, classic mastoiditis, latent mastoiditis, cholesteatoma

Contributor Information and Disclosures

Author

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.

Coauthor(s)

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Dominique C Fontenette, MD, Ewen N Wang, MD, and Alyssa K Hamman, MD, to the development and writing of this article.

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