Acute mastoiditis

Essentials

  • Acute mastoiditis is a rare but serious complication of otitis media.
  • Refer patients with a suspected or definite retroauricular or neck abscess associated with otitis media to specialized care as emergencies.
  • Untreated mastoiditis can lead to intracranial complications.

Epidemiology and symptoms

  • The incidence in children in the Western countries is 2–4 infections/100,000 person-years.
  • Acute and chronic purulent otitis media predisposes to mastoiditis.
  • The clinical picture is associated typically with
    • fever
    • marked pain and tenderness of the ear
    • middle ear effusion or tympanic membrane perforation and otorrhoea
    • hearing loss, tinnitus
    • swelling, redness, and tenderness on percussion of the retroauricular area
    • often impaired general condition.
  • In children the auricle may be turned out- and downwards (lateral displacement).

Diagnosis

  • Clinical picture: see above.
    • Persistent vertigo, facial paresis or a decrease in general condition indicate a severe clinical picture.
  • Laboratory examinations
    • Leucocytosis
    • Increased CRP
  • The primary imaging examination in acute mastoiditis is a CT scan. It shows the collection of fluid in the cavi of the mastoid bone, possible destructive bone changes as well as subperiostal abscesses. If an intracranial complication is suspected, an MRI study is indicated.

Differential diagnosis

  • Otitis externa with swelling of the outer auditory canal. The symptoms are not as severe as in mastoiditis, there is no tenderness or swelling behind the auricle, the results of the laboratory tests are only slightly abnormal, and the mastoid is radiologically normal.
  • If a patient has lymphadenitis of the neck, always examine the ears.
  • In otitis media, there is always fluid in the mastoid air cells but no bone destruction.

Treatment

  • Refer the patient to a specialist unit without delay. If treatment with an intravenous antimicrobial drug, glucocorticoid tablets, middle ear drainage, and topical drops is not successful within 1–3 days, mastoidectomy should be performed. The operation consists of opening and cleansing of the middle ear and the mastoid air cells.
  • Tympanocentesis and middle ear drainage with aspiration, as well as, in most cases, insertion of a tympanostomy tube are indicated to evacuate infectious secretions, to relieve the pressure, to prevent necrosis of the tympanic membrane and to assess treatment response. The discharge from the aspirate provides a sample for bacterial culture to identify the cause of infection.

References

1. Bertolaso C, Cammisa I, Orsini N, et al. Diagnosing acute mastoiditis in a Pediatric Emergency Department: a retrospective review. Acta Biomed 2023;94(2):e2023037  [PMID:37092634]
2. Kaufmann MR, Shetty K, Camilon PR, et al. Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis. Pediatr Infect Dis J 2022;41(4):297-301  [PMID:35175990]
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