DESCRIPTION

• Inflammation of the mastoid air cells of the temporal bone, generally caused by direct extension of acute purulent otitis media
• Middle ear and mastoid air cells are contiguous via the aditus to mastoid antrum
• Fluid accumulation from closure of channel due to otitis media creates opportunity for infection
• Manifestation ranges from clinically insignificant inflammation of mastoid air cells to infection and destruction of the bone
• Acute mastoiditis:
  • Occurs to some degree in all cases of otitis media
  • Early signs and symptoms are those of acute otitis media
  • Usually secondary to contamination with infectious material trapped in the mastoid by inflammatory obstruction of the channel between middle ear and mastoid air cells
• Acute mastoiditis with periostitis:
  • As infection progresses, periosteum of the mastoid bone is involved, causing periostitis
  • Subperiosteal abscess may be present
• Acute mastoid ostitis (also called coalescent mastoiditis):
  • Progression of the infection within the mastoid air cells leads to destruction of the mastoid trabeculae, causing coalescence of bony trabeculae
  • Mastoid empyema or a draining fistula may be present
  • May progress to severe head and neck complications if untreated
• Masked mastoiditis:
  • Mastoid infection, which lingers after an acute otitis media has been treated
  • May progress to acute or coalescent mastoiditis
• Chronic mastoiditis:
  • Infection lasting > 3 mo
• Mastoiditis can be a complication of a primary disorder:
  • Leukemia
  • Mononucleosis
  • Sarcoma of the temporal bone
  • HIV
  • Kawasaki disease
• Mastoiditis used to be more common prior to the use of antibiotics for acute otitis media
• More common in young children and infants

ETIOLOGY

• Organisms in acute mastoiditis are similar to those in acute otitis media, but differ in frequency:
  • Streptococcus pneumoniae
  • Group A streptococcus
  • Staphylococcus aureus
  • Haemophilus influenzae
• Gram-negative enteric bacteria most common with chronic mastoiditis:
  • Pseudomonas aeruginosa
  • Escherichia coli
  • Proteus mirabilis
  • Bacteroides species
• Other less common causes:
  • Mycobacterium tuberculosis
  • Aspergillus species in immunocompromised states

Pediatric Considerations

• More frequently seen in the pediatric population due to strong association with otitis media
• S. pneumoniae is the most common cause in children

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• Ear pain
• Otorrhea
• Mild to severe hearing loss
• Fever
• Headache
• History of irritability in a child
• History of recurrent otitis media

Physical Exam

• Tenderness, edema, and erythema over the mastoid
• Lateral and inferior displacement of the auricle
• Loss of the postauricular crease
• Swelling of the posterior and superior ear canal wall
• Tympanic membrane abnormalities consistent with severe otitis media
• Purulent fluid drainage from the auditory canal
• Bulging tympanic membrane

ESSENTIAL WORKUP

Mastoiditis is a clinical diagnosis

DIAGNOSIS TESTS & INTERPRETATION

Lab

• CBC:
  • Leukocytosis
• Cultures of drainage important owing to diversity of organisms:
  • If spontaneous drainage present or after surgical drainage
• Blood cultures if patient appears toxic

Imaging

• Mastoid plain radiographs:
  • Early stage of disease may show hazy or cloudy but intact mastoid
  • May reveal opacification or coalescence of the mastoid air cells or coalescence as disease progresses
  • Unreliable due to low sensitivity
• CT scan:
  • More useful, especially if abscess formation present
  • Can determine presence and extent of destruction of trabeculae as well as evaluate for the complications of mastoiditis
• MRI:
  • If intracranial involvement suspected but not confirmed by CT

Pediatric Considerations

• Conservative use of CT in children may be warranted
• The diagnosis can often be made on clinical grounds and avoids radiation exposure

Diagnostic Procedures/Surgery

Lumbar puncture:

• Cerebrospinal fluid evaluation for signs of meningitis

DIFFERENTIAL DIAGNOSIS

• Otitis media
• Cellulitis
• External otitis media
• Scalp infection with inflammation of posterior auricular nodes
• Rubella: Posterior auricular node enlargement
• Trauma to pinna or postauricular area
• Meningitis

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

INITIAL STABILIZATION/THERAPY

• ABCs
• Airway management for signs of airway compromise
• 0.9% NS IV fluid bolus for hypotension/volume depletion

ED TREATMENT/PROCEDURES

• Initiate IV antibiotics
• Otolaryngologist consult for surgical drainage:
  • Drainage is the definitive therapy for acute or coalescent mastoiditis
  • Emergent drainage if the patient appears toxic
  • Types of surgical procedures:
    • Myringotomy drainage and tympanostomy tube placement
    • Mastoidectomy and drainage for severe extension (needed in ~50% of cases)

MEDICATION

• Initiate IV antibiotics:
  • Given increasing proportion of S. aureus as causative organism, consider including antistaphylococcal agent before culture results
  • Parenteral antibiotics can be switched to PO after patient afebrile for 36–48 hr
  • Consider antipseudomonal coverage when appropriate
• Administer pain medications:
  • NSAIDs
  • PO or parenteral narcotics

First Line

• Ceftriaxone: 1–2 g (peds: 50–75 mg/kg/24 h) IV q12–24 h
• Cefotaxime: 1–2 g (peds: 50–180 mg/kg/24 h) IV q4–6h

Second Line

• Ampicillin/sulbactam: 1.5–3 g IV q6h
• Chloramphenicol: 50–100 mg/kg/24 h IV or PO q6h
• Clindamycin: 600–2,700 mg/d IV div. q6–12h or 150–450 mg PO q6–8h (peds: 20–40 mg/kg/d IM/IV div. q6–8h or 10–25 mg/kg/d PO div. q6–8h)
• Ticarcillin/clavulanate: 3.1 g IV q4–6h
• Piperacillin/tazobactam: 3.375 g IV q6h
• Vancomycin: 1 g q8h (peds 40 mg/kg/24 h) IV q6–8h

[Outline]

• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Clinical suspicion of acute or coalescent mastoiditis
• Subperiosteal abscess
• Toxic appearing

Discharge Criteria

Patients with acute or coalescent mastoiditis should not be discharged

Issues for Referral

• Otolaryngologist consult for possible surgical drainage
• Audiography should be performed after resolution of mastoiditis to assess hearing loss

FOLLOW-UP RECOMMENDATIONS

Patients should follow up with otolaryngologist after discharge, if not admitted

COMPLICATIONS

• Bezold abscess:
  • Extension of infection to soft tissue below pinna or behind the sternocleidomastoid muscle of neck after erosion through the mastoid tip
• Petrositis:
  • Spread of the infection to the petrous air cells
• Osteomyelitis of the calvarium
• Intracranial complications:
  • Subperiosteal abscess
  • Subdural empyema:
    • Extension of infection to CNS with empyema around the tentorium
  • Sinus thromboses

Pediatric Considerations

Even with conservative management of otitis media, a 10-yr analysis did not show a significant increase in cases of acute mastoiditis.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS
• COMPLICATIONS

• It is important to maintain a high index of suspicion for mastoiditis in setting of persistent or untreated acute otitis media.
• Failure to recognize meningitis or intracranial involvement, which require more aggressive management, is a pitfall
• Drainage is the definitive therapy

ICD9

• 383.00 Acute mastoiditis without complications
• 383.01 Subperiosteal abscess of mastoid
• 383.9 Unspecified mastoiditis

ICD10

• H70.009 Acute mastoiditis without complications, unspecified ear
• H70.019 Subperiosteal abscess of mastoid, unspecified ear
• H70.90 Unspecified mastoiditis, unspecified ear

[Outline]

• ICD9
• ICD10

• Anderson KJ. Mastoiditis. Pediatr Rev. 2009;30:233–234.
• Anthonsen K, Høstmark K, Hansen S, et al. Acute mastoiditis in children. A 10-year retrospective and validated multicenter study. Pediatr Infect Dis J. 2013;32:436–440.
• Devan PP. Mastoiditis. Emergency medicine. Emedicine. Available at http://emedicine.medscape.com/article/784176-overview.
• Liao YJ, Liu TC. Images in clinical medicine. Mastoiditis. N Engl J Med. 2013;368:2014.
• Marx JA, Hockberger RS, Walls RM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
• Tamir S, Schwartz Y, Peleg U, et al. Acute mastoiditis in children: Is computed tomography always necessary? Ann Otol Rhinol Laryngol. 2009;118:565–569.
• Tamir S, Schwartz Y, Peleg U, et al. Shifting trends: Mastoiditis from a surgical to a medical disease. Am J Otolaryngol. 2010;31:467–471.

Jonathan Fisher

Colby Redfield