History
Patients may have unique features of acute and chronic mastoiditis. Acute mastoiditis generally follows a recent or concurrent episode of acute otitis media (AOM) and often results in fever. Presentation varies according to age and the stage of the infection. Chronic disease, which can be subclinical, is often secondary to partial treatment of AOM with antibiotics. Otorrhea that persists longer than 3 weeks is the most consistent sign that a chronic process involving the mastoid has evolved.
Fever may be present (76% of patients). [30] The patient’s temperature may be high. The fever may be unrelenting in acute mastoiditis and may be related to the associated AOM. Persistence of fever, particularly when the patient is receiving adequate and appropriate antimicrobial agents, is common in acute mastoiditis. High fever spikes may be suggestive of sigmoid sinus thrombophlebitis.
Pain may be reported (67% of patients). [30] Pain is localized deep inside or behind the ear and typically worsens at night. Persistence of pain is a warning sign of mastoid disease. This finding may be difficult to evaluate in young patients. Other systemic symptoms and signs may include lethargy, malaise, irritability, poor feeding, or diarrhea.
Hearing loss may occur. This is common with all processes involving the middle-ear cleft. More than 80% of patients have no history of recurrent otitis media.
Nonspecific symptoms (most commonly observed in infants) include poor feeding and irritability.
The clinical findings of acute mastoiditis may differ according to the causative pathogen. S. pneumoniae, especially strains with reduced susceptibility, causes severe symptoms and leads to mastoidectomy more often than the other pathogens. S. pyogenes causes less otalgia than the other pathogens. P. aeruginosa particularly affects children with tympanostomy tubes and causes a less aggressive form of disease. [31]
Physical Examination
Signs of acute mastoiditis include the following [30] :
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Bulging erythematous tympanic membrane
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Tympanic membrane perforation (37%) and otorrhea (50%)
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Erythema, tenderness, and edema over the mastoid area
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Postauricular fluctuance
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Protrusion of the auricle (generally downward and outward in children < 2 y and upward and outward in those >2 y)
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Sagging of the posterosuperior canal wall (71% of patients) [30]
Chronic mastoiditis findings may be consistent with a complication of extension beyond the mastoid process and its overlying periosteum or with another intratemporal complication such as facial palsy. Signs include the following:
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Infected or normal-appearing tympanic membrane
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Absence of external signs of mastoid inflammation
Neurologic examination generally yields nonfocal findings. However, involvement of the cranial nerves can occur with advanced disease. Signs include the following:
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Palsy of the abducens nerve (cranial nerve VI)
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Palsy of the facial nerve (cranial nerve VII)
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Pain from involvement of the ophthalmic branch of the trigeminal nerve
Findings observed in both acute and chronic mastoiditis include periosteal thickening, subperiosteal abscess, otitis media, and nipplelike protrusion of the central tympanic membrane.
Periosteal thickening requires comparison with the other side. Displacement of the auricle downward and outward (especially in children younger than 2 years) or upward and outward (in children younger than 2 years) may be present. Subperiosteal abscess (see the image below) displaces the auricle laterally and obliterates the postauricular skin crease. If the crease remains, the process is lateral to the periosteum.
Mastoiditis with subperiosteal abscess. Note the loss of the skin crease and the pointed abscess.
Otitis media is present at otoscopy, often with additional features. Nipplelike protrusion of the central tympanic membrane may be present; this usually oozes pus.
A persistent low-grade infection (masked mastoiditis) can occur in patients with recurrent otitis media or persistent ear effusion. This condition can cause fever, ear pain, and complications. [32]
Complications
Extracranial complications include the following [33] :
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Facial nerve palsy
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Conductive and sensorineural hearing loss
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Subperiosteal abscess
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Cranial osteomyelitis or bony erosion
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Bezold abscess (a deep abscess in the soft tissues of the neck)
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Labyrinthitis
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Lemierre Syndrome [34]
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Petrositis leading to Gradenigo syndrome (triad of abducens nerve palsy, deep facial pain from trigeminal nerve involvement, and suppurative otitis media)
Intracranial complications include the following [35] :
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Intracranial spread (meningitis; epidural, temporal lobe or cerebral abscess, subdural empyema, subperiosteal abscess)
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Dural sinus thrombosis
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Mastoiditis with subperiosteal abscess. Note the loss of the skin crease and the pointed abscess.
