eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid
Middle Ear, Mastoiditis: Treatment
Updated: Mar 19, 2008
Treatment
Medical Therapy
Antibiotics are the principal medications used in 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 those MDRSP prevalent in the individual 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.
Drug Category: Antibiotics -Therapy must cover all likely pathogens in the context of this clinical setting.
Drug name – Vancomycin (Lyphocin, Vancocin): As an increasing proportion of invasive strains of S pneumoniae are of the MDRSP types, beginning therapy with this medication is thought appropriate. After surgery or after C&S studies confirm sensitivity to other medications, the patient may be prescribed other medications that do not require the same degree of monitoring. For patients demonstrating sensitivity to vancomycin, high-dose ceftriaxone or cefotaxime or possibly rifampin may be used to fulfill criteria noted above and to have efficacy in the management of MDRSP.
Preferred method of administration is the individual analytic method. Adjust initial doses to provide peak levels 25-40 mcg/mL and trough levels <10 mcg/mL. Half-life is 4-8 h.
Adult Dose – 40 mg/kg/d IV divided q6-12h
Pediatric Dose – Empiric method: 40-60 mg/kg/d IV divided q6-8h; not to exceed 2 g/d
Contraindications – Documented hypersensitivity
Interactions – Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; when taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Pregnancy – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions - Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction; ototoxic, possibly nephrotoxic (monitor levels if possible); severe hypotension may occur with rapid administration; wheezing, pruritus, and cardiac arrest are infrequent occurrences
Drug name – Ceftriaxone (Rocephin): Third-generation cephalosporin with broad-spectrum, gram-negative activity.
Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult Dose – 1-2 g/dose IV q12-24h
Pediatric Dose – Meningitis dose: 100-160 mg/kg/d IV q1-2d, then 60-100 mg/kg/d IV divided q12-24h
Contraindications – Documented hypersensitivity
Interactions – Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy – Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions - Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; half-life 6-9 h; toxicity, allergy (rash, pruritus, fever, chills), local irritation, nausea, diarrhea, pseudomembranous colitis, thrombocytosis, leukopenia, eosinophilia, elevated BUN level; caution in breastfeeding women and persons with allergy to penicillin
Drug name – Rifampin (Rifadin, Rimactane): Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which in turn blocks RNA transcription.
Adult Dose – 20 mg/kg/d PO/IV divided q12h; not to exceed 600 mg/dose; well absorbed from GI tract
Pediatric Dose – Administer as in adults
Contraindications – Documented hypersensitivity
Interactions – Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin
Blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Pregnancy – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions - Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs
If treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; eliminated in biliary system (40-45%) and renal system (30-40%); discolors urine, saliva, sweat, tears, and stains some contact lenses; half-life is 1.5-3 h; toxicity, GI irritation, allergy, neurological headache, confusion, ataxia, blood dyscrasias, hepatic dysfunction, fatigue, and fever may occur
Drug name – Cefotaxime (Claforan): Third-generation cephalosporin, crosses blood-brain barrier and may be effective against MDRSP. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth.
Adult Dose – 1-2 g IV q4-6h; not to exceed 12 g/d
Pediatric Dose – 150-200 mg/kg/d IV divided q4-8h; not to exceed 12 g/d
Contraindications – Documented hypersensitivity
Interactions – Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Pregnancy – Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions - Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs
If treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; eliminated in biliary system (40-45%) and renal system (30-40%); discolors urine, saliva, sweat, tears, and stains some contact lenses; half-life is 1.5-3 h; toxicity, GI irritation, allergy, neurological headache, confusion, ataxia, blood dyscrasias, hepatic dysfunction, fatigue, and fever may occur
Consultations
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.
Transfer
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.
Surgical Therapy
Surgical therapy confined to the ear includes myringotomy/tympanocentesis, tympanostomy tube placement, and mastoidectomy.
Myringotomy/tympanocentesis
This is primarily used to obtain specimens and to relieve discomfort from AOM. These openings usually heal within a few days.
Tympanostomy tube placement
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.
Mastoidectomy
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. 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.
Preoperative Details
Warn patients and their families of possible cosmetic deformity following mastoid surgery.
Preoperative preparation entails shaving the area behind the involved side (in the postaural area) a width of 3 fingers to avoid wound contamination.
Intraoperative Details
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.
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 diathermized. 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.
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 triangular-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.
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.
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.
Postoperative Details
Monitor the patient's temperature; it usually falls dramatically within the first 24 hours, after which the patient can be allowed up. If all diseased cells are cleared, the discharge completely ceases, and the ear dries and heals in the ensuing few days (usually in about a week), the patient can then return to normal activities.
The firm pressure dressing is removed on the sixth postoperative day, when stitches are removed.
Follow-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.
Complications
Complications associated with mastoiditis
Meningitis and facial nerve paralysis are possible. Despite use of antibiotics, acute mastoiditis still remains a threat for patients with AOM, especially for children younger than 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.
Approximately 7% of patients may develop intracranial complications related to acute mastoiditis. These complications can include sigmoid sinus thrombosis, epidural abscess, and meningitis. Persistent otalgia or otorrhea with associated neurologic symptoms in a patient taking oral antibiotics are ominous signs that suggest a complication.
Otogenic meningitis is the most common intracranial complication of neglected otitis media. In the western world, such complications seldom occur in children and adolescents and are extremely rare in adults. The current use of antibiotics and of more sophisticated surgery has greatly diminished the incidence of otogenic meningitis; however, this has resulted in physicians having less experience with diagnosis and treatment of this complication. Emergency surgical treatment is mandatory.
In a study done by Luntz et al, of 223 consecutive cases of acute mastoiditis, sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy).1
A study by Niv et al concluded that (1) A significant increase in the incidence of AM in infants was recorded over the last decade, although a specific reason for this trend remains uncertain; (2) most of the cases of AM followed the infant's initial AOM episode, and most of the infants had not received prior antibiotic therapy; (3) the clinical signs and symptoms of AM were more severe in infants than in older patients; (4) Although S pneumonia was the most common pathogen isolated in middle ear fluid cultures, the involvement of S pyogenes in AM was higher than that reported in AOM.2
Bezold abscesses are very rare complications and are usually found only in adults with a well-pneumatized mastoid tip.
Complications associated with mastoidectomy
- 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
- This 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.
- Complete facial nerve paralysis
- If 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
- This 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.
Additional intracranial complications are possible following mastoidectomy.
Although mastoidectomy is a common surgical procedure in otology, postoperative complications of various degrees of severity may occur. Complications reported include brain abscess one 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.
Medicolegal pitfalls
Medicolegal pitfalls relate almost entirely either to delay of diagnosis or to iatrogenic injury during therapy. A high index of suspicion, judicious use of diagnostic modalities, and close follow-up care are recommended to make a diagnosis in a timely manner. 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.
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References
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Kaplan SL, Mason EO Jr, Wald ER, Kim KS, Givner LB, Bradley JS, et al. Pneumococcal mastoiditis in children. Pediatrics. Oct 2000;106(4):695-9. [Medline].
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Further Reading
Keywords
mastoiditis, acute surgical mastoiditis, ASM, chronic middle ear inflammatory disease, chronic suppurative otitis media, acute otitis media, AOM, acute mastoiditis, earache, ear ache, ear pain, ear infection, hearing loss, cholesteatoma, middle ear disease, coalescent mastoiditis, mastoid, mastoidectomy, tympanocentesis, mastoid disease
