http://www.ncbi.nlm.nih.

gov/pmc/articles/PMC3216184/

Mastoid Abscess in Acute and Chronic Otitis Media

Mazita Ami, Zahirrudin Zakaria, [...], and Lokman Saim
Additional article information

Abstract
Background:
Mastoid abscess remains a recognised complication of otitis media despite the advent of antibiotics. The objectives of this study were to describe the risk factors in patients with mastoid abscess following acute and chronic otitis media and discuss the management of this infection.

Method:
A retrospective analysis was done on all patients who underwent mastoidectomy for mastoid abscess from January 2002 to December 2007. Data on the patients presentation, associated complications, management, and follow-up were analysed.

Results:
A total of 12 patients were enrolled in this study population. Group A consisted of patients with mastoid abscess preceded by acute otitis media, while Group B consisted of patients with mastoid abscess and chronic otitis media. In Group A (n = 7), 4 patients had a pre-morbid immunocompromised condition, but they did not have cholesteatoma. None of the patients in Group B (n = 5) had any pre-morbid illnesses. Out of 12 patients, 7 patients had associated extracranial complications, and 1 patient had intracranial complications. Most patients recovered well after mastoidectomy. Recurrence was noted in 1 patient who had acute lymphoblastic leukaemia.

Conclusion:
Mastoid abscess is still a recognised complication of acute otitis media, especially in patients who are immunocompromised. Immunocompetent patients may also develop mastoid abscess following chronic otitis media associated with cholesteatoma. Thus, early treatment of otitis media and close vigilant follow-up are advocated to ensure prompt detection of mastoid abscess complications.
Keywords: abscess, cholesteatoma, complications, immunocompromised patient,

mastoiditis, otitis media, otolyngology; head neck

Introduction
In the era of antibiotics, mastoid abscess is an uncommon complication of otitis media. This has resulted in a decline in the incidence of mastoidectomy performed for mastoid abscess. Nevertheless, there are still a number of patients who develop mastoid abscess, which requires prompt diagnosis and management. Records of patients who underwent mastoidectomy for mastoid abscess at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) were reviewed. The objective of this review was to study the characteristics of patients who may have a higher risk of developing mastoid abscess following acute or chronic otitis media (COM).

Materials and Methods

This is a retrospective analysis of patients who underwent mastoidectomy for mastoid abscess in UKMMC from 2002 to 2007. The operative census was reviewed to identify patients who underwent mastoidectomy for mastoid abscess. The medical records of these patients were reviewed to confirm the diagnosis of mastoid abscess intra-operatively. The diagnosis of mastoid abscess was defined by findings of pus within the coalescent mastoid air cells. This study was approved by the Research and Ethics Committee of UKMMC (FF-242-2008).

Results
A total of 13 patients were identified in this study, and their ages ranged 370 years old with a mean of 30.4 years old. Further data of 1 patient could not be traced and

had to be omitted, which left a total of 12 cases. The patients were classified into 2 groups: Group A consisted of patients with mastoid abscess preceded by acute otitis media (AOM), and Group B consisted of patients with mastoid abscess and underlying COM. AOM was defined as having symptoms for duration of less than 12 weeks, and cases were classified as COM when symptoms persisted for 12 weeks or longer. All patients in this series presented with unilateral ear infection.

Group A: Patients diagnosed with AOM with mastoid abscess

There were 7 patients categorised into Group A (Table 1). All paediatric patients (n = 3, age less than 12 years old) in this study were in this group. These patients had aural symptoms between 3 and 28 days prior to presentation. Post-auricular swelling was present in 3 patients, mastoid pain was present in 4 patients, and otorrhoea was present in 2 patients. Otoscopic examination revealed perforated tympanic membrane in 2 patients.

Table 1: Demographics of patients diagnosed with acute otitis media with mastoid abscess (Group A)

There were 5 out of 7 patients who had other associated complications. There were also 4 out of 7 patients in this group who had pre-morbid conditions leading to a relatively immunocompromised state compared to the other subjects. Cholesteatoma, however, was not noted in any of these patients.

Group B: Patients diagnosed with mastoid abscess and underlying COM

There were 5 patients categorised into Group B (Table 2). In this group, the patients had chronic aural symptoms for 3 to 12 months and acute (new) symptoms for 2 to 6 weeks prior to presentation. Post-auricular swelling was present in 3 patients, mastoid pain was present in 4 patients, and otorrhoea was present in 3 patients.

Otoscopic examination revealed that all patients had a perforated tympanic membrane. It was noted that only 3 out of the 5 patients had other associated complications. All 3 patients had underlying cholesteatoma, but none of these patients had any pre-morbid illnesses.

Table 2: Demographics of patients diagnosed with acute otitis media with mastoid abscess (Group B)

Associated complications of otitis media

Out of 12 patients, 8 (66.7%) had complications of mastoiditis. These were mainly extracranial complications, in 7 out of 8 patients: facial nerve palsy, in 3 patients, Bezolds abscess, in 3 patients (Figure 1), and zygomatic root abscess in 1 patient (Figure 2). In this series, only 1 patient had an associated intracranial complication of meningitis.

Figure 1: Coronal CT scan of a patient diagnosed with left mastoid abscess and Bezolds abscess (arrow)

Figure 2: Axial CT scan of temporal bone showing right mastoid abscess and zygomatic root abscess (arrows)

Management and follow-up

All patients were admitted and started on broad-spectrum intravenous antibiotics. Intravenous ceftriaxone was chosen because of its good blood-brain barrier penetration. Ceftriaxone was administered at a dose of 1 g daily, unless patients had intracranial complications, which required a dose of 2 g twice daily. The type of antibiotics was modified according to the culture results. The duration of antibiotic treatment was 2 weeks in all patients. The bacteria isolated from patients pus culture were Staphylococcus aureus in 3 patients, Klebsiella pneumoniae in 2 patients, coagulase-negative Staphylococcus spp in 1 patient and Pseudomonas aeruginosa in 1 patient. There were 2 patients with mixed growth, but the cultures contained predominantly Enterococcus spp. The other 5 patients had no growth on operative specimen or swab culture. All of the patients in this series had mastoid exploration for abscess drainage and eradication of diseased mastoid air cells. Modified radical mastoidectomy was performed in almost half of the patients (5 out of 12 patients). Cortical mastoidectomy with myringotomy and ventilation tube insertion was performed in 4 patients, and 3 of those patients had AOM. Radical mastoidectomy was only performed in 2 patients (1 from each group). Post-operatively, all patients had a good recovery. The average follow-up period was 24 months (range 858 months), and 2 out of 12 patients were lost during the postoperative follow-up. Only 1 patient with acute lymphoblastic leukaemia (ALL) in Group A had a recurrence of mastoid abscess, which occurred 1 month later. The patient with ALL developed AOM while undergoing chemotherapy; the patient was treated with amoxicillin. Despite treatment compliance, the patient developed lower motor neuron facial nerve palsy 5 days later. Radical mastoidectomy was performed, which showed a bony dehiscent over the horizontal segment of the facial nerve which was covered by granulation tissue. The stapes suprastructure was also absent. Post-operatively, the facial nerve palsy improved from HouseBrackmann grade IV to grade II. However, he had another episode of AOM with facial nerve palsy grade V a month later. Unfortunately, due to pancytopenia and a poor general

condition, he was deemed unfit for another mastoid exploration. This patient later succumbed to the underlying haematological malignancy.

Discussion
The complications of otitis media are broadly categorised into extracranial and intracranial complications. Extracranial complications (such as mastoiditis, subperiosteal abscess, facial paralysis, and labyrinthitis) and intracranial complications (such as cerebral or extradural abscess, meningitis, focal encephalitis, lateral sinus thrombosis, and otic hydrocephalus) are more likely to be associated with AOM than COM (13). Since the introduction of antibiotics in the 1940s, the incidence of acute mastoiditis and surgical intervention has declined. Recent publications, however, have noted an increase in the incidence of acute mastoiditis following AOM in children (4,5). Conversely, there has been a reduced incidence of COM since the 1990s. However, the rate of extracranial and intracranial complications has remained stable (6). There have been significant socioeconomic improvements in many countries during this time. This is important because the established risk factors associated with COM include low socioeconomic class, malnutrition, and congested living conditions (7). Therefore, these studies seem to suggest an increased incidence of mastoiditis following AOM compared with COM. Mastoiditis has often been recognised as an extracranial complication of otitis media when patients develop tender post-auricular swelling. The current treatment of mastoiditis is mainly antibiotics with surgery reserved to myringotomy (5,8). Mastoid abscess may develop as a complication of mastoiditis following both AOM and COM (911). It occurs when purulent material collection accumulates within the middle ear and mastoid air cells, and it is often accompanied by granulation tissue. Surgical intervention is still the most common treatment for mastoid abscess. Therefore, it is important to distinguish mastoid abscess from uncomplicated mastoiditis and manage patients accordingly. The most common clinical presentation of mastoid abscess in this series was a tender, fluctuant post-auricular swelling, which was similar to other cases in the

literature (11,12). Otorrhoea was less common, and facial asymmetry, neck swelling, and meningism were even rarer. All of the patients with cholesteatoma had a history of chronic otorrhoea since childhood. Complications following COM were more prevalent in subjects with cholesteatoma (13). Mustafa et al. showed that 15% of patients with COM had associated cholesteatoma, and one-third of them presented with complications. In COM without cholesteatoma, only 6.7% presented with complications. In the current series, the numbers were too small to make any significant comparison; however, 3 out of 5 patients with mastoid abscess following COM had cholesteatoma. Interestingly, the incidence of multiple complications can occur between 11% and 58% of cases and appears to be more prevalent in patients with intracranial complications (1315). Not surprisingly, the complication rate following COM has been reported to be higher than that following AOM (14,15), but caution should be exercised in young children with AOM because intracranial complications may occur relatively rapidly in the course of the disease (16). In this series, there was only 1 patient with meningitis as a complication of mastoid abscess. However, patients with mastoiditis or mastoid abscess who did not undergo mastoid surgery was excluded; therefore, the series may not have captured these cases. In our centre, patients with suspected mastoid abscess following mastoiditis were promptly admitted and commenced on broad-spectrum intravenous antibiotics. A high-resolution CT of the temporal bone and contrast-enhanced CT of the brain were also performed in all patients. Mastoidectomy with abscess drainage was indicated when there was purulent collection clinically, evidence on the CT scan or in patients with cholesteatoma. The predominant organisms cultured in this series were Staphylococcus aureus and Klebsiella pneumoniae; however, there was no single predominant organism in AOM or COM. There were 5 (42%) patients samples that exhibited no growth on routine cultures. Previous antibiotic treatment may have resulted in the absence of bacterial growth (4). In addition, tests for anaerobic cultures were not routinely performed in our institution when anaerobes are expected to be prevalent in COM. Previous studies have shown that common organisms in AOM include Streptococcus

pneumoniae and Haemophilus spp. whereas common organisms in COM include Proteus mirabilis, Enterococcus spp., and Pseudomonas aeruginosa (5,1315,17). Mastoidectomy was performed expediently once the patients medical condition was stabilised, and the decision to bring down the posterior canal wall or to perform radical mastoidectomy was depended on the intra-operative findings. Generally, intra-operative findings of intact ossicles with no cholesteatoma indicated cortical mastoidectomy with myringotomy (if the tympanic membrane was intact). In this series, intra-operative findings of ossicular erosion, including erosion of the stapes suprastructure, led to radical mastoidectomy in two patients. Interestingly, serious co-morbidities were noted to be present in patients who developed mastoid abscess following AOM. The only 4 (25%) patients with premorbid illness were those who developed mastoid abscess following AOM. These premorbid conditions included ALL in 1 patient, BTM in 1 patient, and diabetes mellitus in 2 patients. It is postulated that an immunocompromised state due to illness may make a patient susceptible to developing mastoid abscess following AOM. Factors that have been shown to influence the spread of infection include the type and virulence of the infecting organism, host resistance, and the adequacy of treatment (15). Patients with haematological malignancy, such as ALL, may present with leukaemic infiltration of the temporal bone; however, this is uncommon. Moreover, surgical findings often revealed greenish soft tissue mass with gelatinous fluid within the middle ear (18), which was not evident in our patient. In this case, it is postulated that enhanced organism virulence might explain the extensive ossicular destruction despite the acute presentation. Interestingly, a study showed that patients with BTM were prone to infection due to impaired phagocytic action and anaemia (19). They are also prone to recurrent upper respiratory tract infections because of generalised lymphoid hyperplasia and expanding marrow of facial bones, which results in nasal obstruction. Patients with diabetes mellitus may present with masked symptoms due to neuropathy. Both patients with diabetes mellitus developed mastoid abscess with associated complications of meningitis or Bezolds abscess in the absence of otorrhoea symptoms. The immunocompromised condition

of these 4 patients could have resulted in the dissemination of infection before any apparent ear symptoms. Therefore, early adequate treatment of AOM and close vigilant follow-up are important, especially in immunocompromised patients. Antibiotic treatment, however, does not provide absolute protection against the development of complications and, at worst, may mask the symptoms and signs of complications (4,16). Increasing antibiotic resistance behaviours by organisms in biofilms (demonstrated in Streptococcus pneumonia and Haemophilus influenza) may explain why antibiotic treatment does not provide absolute protection (17). Facial nerve palsy occurred in 4 out of 12 patients in this series; 3 were patients with AOM had facial nerve palsy grade IV to VI (HouseBrackmann), which improved after surgery (to grade II at best). The other patient had COM and grade II facial palsy, which had improved to grade I on the second post-operative day. These observations were in contrast to previous studies, which reported total recovery in all AOM patients with facial paralysis (20,21). They were also in contrast to another study, which suggested that facial paralysis in COM had a poor prognosis (22). A literature review by White and McCans (23) suggested that several potential processes were involved in facial palsy secondary to otitis media: 1) direct involvement of the facial nerve by bacterial invasion, 2) mechanical compression on the vascular supply of the nerve by the purulent exudates or granulation tissue, 3) acute toxic neuritis with venous thrombosis resulting in ischaemia, and 4) bacterial toxins that lead to facial nerve demyelination. More than one of these processes may be involved in the pathophysiology of facial palsy. Therefore, it is postulated that the recovery of facial nerve function may depend on the underlying pathophysiological processes that resulted in the facial nerve palsy. Recent studies using the results of electrophysiological tests have shown that facial nerve palsy secondary to AOM may be treated clinically (24,25). Another study on facial nerve palsy due to non-cholesteatomatous otitis media also showed good recovery without surgical decompression of the nerve (25,26). However, facial nerve palsy associated with cholesteatoma tends to have a poor prognosis, and mastoid surgery is required to create a safe and dry ear.

Conclusion
Despite the advancements in the treatment of otitis media, mastoid abscess is still a recognised complication in both acute and COM. Although mastoid abscess can occur over a wide age spectrum (370 years old), it predominantly occurs in adults. Patients who are immunocompromised have a greater risk of developing mastoid abscesses secondary to AOM. They may also present with vague symptoms, severe disease or other associated complications that require vigilance on the part of the physician. Mastoid abscesses may also develop in immunocompetent patients with COM, especially in association with cholesteatoma. In contrast to previously published data, facial palsy secondary to AOM may not recover completely.

Footnotes
Authors Contributions Conception and design: MA Provision of study materials or patients: GBS, AA Collection and assembly of data: ZZ Analysis and interpretation of the data: ZZ Drafting of the article: MA, ZZ Critical revision of the article: MA, GBS, AA Final approval of the article: LS

Article information
Malays J Med Sci. 2010 Oct-Dec; 17(4): 4450. PMCID: PMC3216184 Mazita Ami,1 Zahirrudin Zakaria,2 Bee See Goh,1 Asma Abdullah,1 and Lokman Saim1 Department of OtorhinolaryngologyHead and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia
1 2

Department of Otorhinolaryngology, Hospital Pulau Pinang, 10990 Pulau Pinang, Malaysia

Correspondence: Dr Mazita Ami, MS (ORLHNS), Department of OtorhinolaryngologyHead and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia, Fax: +603- 91737840, E-mail: mazitaami/at/yahoo.com

Received November 1, 2009; Accepted March 18, 2010. Copyright Penerbit Universiti Sains Malaysia, 2010 Articles from The Malaysian Journal of Medical Sciences : MJMS are provided here courtesy of School of Medical Sciences, Universiti Sains Malaysia

References
1. Verhoeff M, van der Veen EL, Rovers MM, Sanders EA, Schilder AG. Chronic suppurative otitis media: A review. Int J Paediatr Otorhinolaryngol. 2006;70(1):1 12.[PubMed] 2. Leskinen K. Complications of acute otitis media in children. Curr Allergy Asthma Rep.2005;5(4):308312. [PubMed] 3. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol.2005;30(6):511516. [PubMed] 4. Benito MB, Gorricho BP. Acute mastoiditis: Increase in the incidence and complications.Int J Paediatr Otorhinolaryngol. 2007;71(7):10071011. [PubMed] 5. Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, et al. Acute mastoiditisthe antibiotic era: A multicenter study. Int J Paediatr Otorhinolaryngol.2001;57(1):19. [PubMed] 6. Lin YS, Lin LC, Lee FP, Lee KJ. The prevalence of chronic otitis media and its complications rates in teenagers and adults. Otolaryngol Head & Neck Surg.2009;140(2):165170. [PubMed] 7. Lasisi AO, Olaniyan FA, Muibi SA, Azeez IA, Abdulwasiu KG, Lasisi TJ, et al. Clinical and demographic risk factors associated with chronic suppurative otitis media. Int J Paediatr Otorhinolaryngol. 2007;71(10):15491554. [PubMed] 8. Tamir S, Shwartz Y, Peleg U, Shaul C, Perez R, Sichel JY. Shifting trends: Mastoiditis from a surgical to a medical disease. Am J Otolaryngol. 2010;31(6):467471. [PubMed] 9. Migirov L, Yakirevitch A, Kronenberg J. Mastoid subperiosteal abscess: A review of 51 cases. Int J Paediatr Otorhinolaryngol. 2005;69(11):15291533. [PubMed] 10. Bauer PW, Brown KR, Jones DT. Mastoid subperiosteal abscess management in children. Int J Paediatr Otorhinolaryngol. 2002;63(3):185188. [PubMed] 11. Al-Serhani AM. Mastoid abscess: Underlying disease and management. Am J Otol.1996;17(5):694696. [PubMed] 12. Pang HYL, Barakate MS, Havas T. Mastoiditis in a paediatric population: A review of 11 years experience in management. Int J Pediatr Otorhinolaryngol. 2009;73(11):1520 1524.[PubMed]

13. Mustafa A, Heta A, Kastrati B, Dreshaj Sh. Complications of chronic otitis media with cholesteatoma during a 10-year period in Kosovo. Eur Arch Otorhinolaryngol.2008;265(12):14771482. [PubMed] 14. Penido Nde O, Borin A, Iha LCN, Suguri VM, Onishi E, Fukuda Y, et al. Intracranial complications of otitis media: 15 years experience in 33 patients. Otolaryngol Head Neck Surg. 2005;132(1):3742. [PubMed] 15. Kangsanarak J, Navacharoen N, Fooanant S, Ruckphaopunt K. Intracranial complications of suppurative otitis media: 13 years experience. Am J Otol.1995;16(1):104109. [PubMed] 16. Dhooge IJM, Albers FWJ, Van Cauwenberge PB. Intratemporal and intracranial complications of acute suppurative otitis media in children: Renewed interest. Int J Paediatr Otorhinolaryngol. 1999;49(Suppl 1):S109S114. [PubMed] 17. Vergison A. Microbiology of otitis media: A moving target. Vaccine. 2008;26(Suppl 7):G5G10. [PubMed] 18. Almadori G, Ninno MD, Cadoni G, Di Mario A, Ottaviani F. Facial nerve paralysis in acute otomastoiditis as presenting symptom of FAB M2, T8;21 leukemic relapse. Case report and review of the literature. Int J Paediatr Otorhinolaryngol. 1996;36(1):45 52.[PubMed] 19. Wanachiwanawin W. Infections in E-beta Thalassemia. J Pediatr Hematol Oncol.2000;22(6):581587. [PubMed] 20. Zinis LOR, Gamba P, Balzanelli C. Acute Otitis Media and Facial Nerve Paralysis in Adults. Otol Neurotol. 2003;24(1):113117. [PubMed] 21. Leskinen K, Jero J. Complications of acute otitis media in children in Southern Finland.Int J Paediatr Otorhinolaryngol. 2004;68(3):317324. [PubMed] 22. Yetiser S, Tosun F, Kazkayasi M. Facial Nerve Paralysis Due to Chronic Otitis Media.Otol Neurotol. 2002;23(4):580588. [PubMed] 23. White N, McCans KM. Facial paralysis secondary to acute otitis media. Pediatr Emerg Care. 2000;16(5):343345. [PubMed] 24. Yonamine FK, Tuma J, Silva RF, Soares MC, Testa JR. Facial paralysis associated with acute otitis media. Braz J Otorhinolaryngol. 2009;75(2):228230. [PubMed] 25. Makeham TP, Croxson GR, Coulson S. Infective causes of facial nerve paralysis. Otol Neurotol. 2007;28(1):100103. [PubMed] 26. Ozbek C, Somuk T, Cifti O, Ozdem C. Management of facial nerve paralysis in noncholesteatomatous chronic otitis media. B-ENT. 2009;5(2):7377. [PubMed]

http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm

Mastoiditis
The mastoid process is an inferior extension of the petrous temporal bone of the skull and provides a structural function as an anchor point for the large muscles of the neck. It contains multiple air cells that develop from a single main cavity (the antrum), after the age of about two. In cross-section, it has a vacuolated or honeycomb appearance. The tympanic cavity of the middle ear is in communication with the mastoid antrum via a small canal that runs through the petrous temporal bone. The mastoid air cells are related superiorly to the middle cranial fossa, and posteriorly to the posterior cranial fossa. This means that suppuration in the mastoid may, rarely, spread to cause meningitis or a cerebral abscess. Other surrounding structures include the facial nerve canal, the sigmoid sinus and the lateral sinus. Mastoiditis occurs when suppurative infection extends from a middle ear affected byotitis media to the mastoid air cells. The infective process causes inflammation of the mastoid and surrounding tissues and may lead to bony destruction.

Classification[1]

Classic, or acute, mastoiditis is a rare complication of acute otitis media (AOM). Chronic, latent, or masked, mastoiditis presents in a chronic, or subclinical, fashion. It is usually associated with chronic suppurative otitis media or cholesteatoma.

Epidemiology

Mastoiditis in acute or chronic form is now quite rare. Before the advent of antibiotics, mastoiditis was relatively common. It developed in 5-10% of children with acute otitis media (AOM), with a mortality rate of 2 per 100,000 children. The mortality rate is now <0.01 per 100,000 children.[2] Current rates are in the order of 0.12 diagnoses per 1,000 child-years.[3] The rates of mastoiditis seem to be higher in countries where antibiotic prescribing rates for AOM are lower but this, in itself, does not prove a causal relationship.[3][4] If a causal link is assumed, it is estimated that the numbers needed to treat with antibiotics are 50,000 children to avoid one child developing mastoiditis.[5] As serious complications are rare, guidance is that the routine use of antibiotics in AOM is not thought to be justified by the potential reduction in risk of these complications.[4][6][7][8][9] See separate article Acute Otitis Media. A BMJ review looked at trends in antibiotic prescribing rates in UK general practice between 1993 and 2003 and admissions for peritonsillar abscess, mastoiditis and rheumatic fever in children between 1993 and 2002. Antibiotic prescribing rates halved during this time but hospital admission

rates for mastoiditis had increased by 19% over the preceding 10 years.[6] The authors suggested that the apparent increase could reflect coding error and that the reduction in general practice events could reflect the fact that sick children are increasingly being taken straight to hospital.

Risk factors

Much more common in young children, with peak incidence at age 6-13 months.[1] Patients with immunocompromise may be more prone to mastoiditis. Children or adults with intellectual impairment or communication difficulties are thought to be susceptible to the condition, possibly as a result of not being able to communicate their symptoms. Pre-existence of cholesteatoma is a risk factor for subsequent mastoiditis.

Infecting organisms[1]
Streptococcus pneumoniae (most frequently isolated). S. pyogenes. Staphylococcus spp. Haemophilus influenzae. Pseudomonas aeruginosa (becoming increasingly common).[1] Moraxella catarrhalis. Other Gram-negative organisms (occur more frequently in chronic form). Mycobacteria (rare). Aspergillus and other fungi (rare).

Presentation
Acute (classic) mastoiditis

History of acute or recurrent episodes of otitis media. Otalgia and pain behind the ear. Fever. Infants may present with irritability, intractable crying and feeding problems. Swelling, redness or a boggy, tender mass behind the ear. The external ear may protrude forwards; fluctuance can sometimes be demonstrated behind the ear (examine from behind). Ear discharge may be present and the eardrum may be perforated. Tympanic membrane bulges and is erythematous. The patient is unwell. Presents in a subtle or subclinical fashion after an episode of acute otitis media (AOM) or with history of chronic suppurative otitis media. Recurrent bouts of otalgia and retro-aural pain. Recurrent headache. Episodes of fever. Infants may present with irritability, intractable crying and feeding problems. Tympanic membrane may appear infected or may be normal. May be no external evidence of peri-mastoid inflammation. Examine for evidence of local neurological involvement. There may be an ipsilateral VIth or VIIth cranial nerve palsy, or pain over the distribution of the ophthalmic division of the Vth cranial nerve.

Chronic mastoiditis

Other points on examination

The patient may complain of deafness and there may be signs of conductive deafness(Rinne's test negative; Weber's test - sound localised/loudest in the affected ear). There may be no history of otitis media, no mastoid area tenderness and no external signs of infection.[1]

Differential diagnosis

Otitis media or externa. Trauma to the ear/mastoid. Cervical lymph node enlargement. Meningitis. Cellulitis. Parotid swelling. Bone cysts or tumours. Basal skull fracture. Other source of intracranial or localised sepsis. Pyrexia of unknown origin.

Investigations

FBC may show leukocytosis. ESR may be elevated. Blood cultures should be taken. Fluid can be extracted from the middle ear through perforated drums or by intervention (tympanocentesis) and should be sent for Gram staining, culture and acid-fast stain.[1] Skull X-ray of the mastoid area is not usually helpful but may show clouding of mastoid air cells. CT and/or MRI scanning can be used for to aid diagnosis and look for intracranial complications. Some say that CT scanning should be used in all suspected cases of mastoiditis and others suggest a more conservative approach.[1][10] In addition, MRI may be less useful than CT scanning.[11] Lumbar puncture should be carried out if intracranial spread is suspected. Audiograms during and after mastoiditis help to quantify and monitor any associatedhearing loss.

Management

Patients with suspected mastoiditis should be managed in a hospital setting. Appropriate clinical suspicion and prompt diagnosis are important to reduce the likelihood of complications. The usual initial therapy is high-dose, broad-spectrum intravenous (IV) antibiotics, given for at least 1-2 days (eg with a third-generation cephalosporin).[1] Oral antibiotics are usually used after this, starting on IV treatment after 48 hours without fever, and continuing for at least 1-2 weeks. Paracetamol, ibuprofen and other agents may be given as antipyretics and/or painkillers. Myringotomy tympanostomy tube insertion may be performed in some cases as a therapeutic procedure, or to collect middle ear fluid for culture.

Surgical intervention, usually in the form of mastoidectomy tympanoplasty, is suggested if there is:[1] Mastoid osteitis. Intracranial extension. Abscess formation. Co-existing cholesteatoma. Limited improvement after IV antibiotics. Mastoidectomy can be:[1] Simple: infected mastoid air cells are removed. Radical: the tympanic membrane and most middle ear structures are removed and the Eustachian tube is closed. Modified: the ossicles and part of the tympanic membrane is preserved. Incision and drainage of a subperiosteal abscess in another procedure that may be required. Patients with intracranial spread may also need neurosurgical intervention. In cases with unusual infecting organisms, specialist infectious disease input may be helpful.

Complications

Conductive and/or sensorineural hearing loss. Osteomyelitis or bone erosion. Extension to the zygoma (zygomatic mastoiditis). Subperiosteal abscess (abscess between the periosteum and mastoid bone; gives appearance of a protruding ear). Cranial nerve palsies (especially V, VI and VII). Intracranial spread leading to extradural abscess, cerebral abscess, subdural empyema and meningitis. Intracranial venous sinus thrombosis (eg lateral sinus thrombosis). Bezold's abscess (spread of pus from mastoid process along the digastric muscle to other neck muscles).[12] Petrositis causing Gradenigo's syndrome (VIth cranial nerve palsy + deep trigeminalfacial pain + suppurative otitis media). Carotid artery spasm, arteritis, occlusion, rupture or metastatic septic emboli leading to intracerebral infection (all very rare and associated with the most severe cases).

Prognosis
Nowadays the prognosis for the vast majority of cases that are diagnosed early is excellent with a low chance of complications or severe hearing loss. A recent review reported that most who had suffered an episode of acute mastoiditis had no long-term otological sequelae.[13] However, complicated cases may still lead to significant morbidity or even death.

Prevention
The disease itself is difficult to prevent, except possibly by electing to treat some severe cases of acute otitis media (AOM) with adequate doses and duration of appropriate antibiotics. The sequelae of the condition can be prevented by having an appropriate index of suspicion for the condition and admitting patients suspected of having mastoiditis for early hospital assessment.

Medicolegal considerations
Failure to diagnose mastoiditis leading to life-threatening complications or death, is a recurrent, if relatively rare, cause of legal claims made against general practitioners in the UK. It should be borne in mind that the symptoms and signs can be quite subtle in chronic or latent mastoiditis. Provide Feedback

Further reading & references

1. 2. 3. 4. 5. 6.

7. 8. 9.

10. 11. 12. 13.

Kavanagh K; Acute Coalescent Mastoiditis, Otology online, ENT USA.; good images including the protruding auricle Chase KS et al; Mastoiditis, Medscape, Sep 2009 Bluestone CD; Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J. 2000 May;19(5 Suppl):S37-46. Brook I; Antimicrobial therapy of otitis media reduces the incidence of mastoiditis. Curr Infect Dis Rep. 2010 Jan;12(1):1-3. Otitis media - acute, Clinical Knowledge Summaries (July 2009) Damoiseaux RA; Antibiotic treatment for acute otitis media: time to think again. CMAJ. 2005 Mar 1;172(5):657-8. Sharland M, Kendall H, Yeates D, et al; Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis. BMJ. 2005 Aug 6;331(7512):328-9. Epub 2005 Jun 20. Glasziou PP et al.,; Antibiotics for acute otitis media in children. Cochrane review abstract and plain language summary. Cochrane Database of Sytematic Reviews. 2006(2). Diagnosis and management of childhood otitis media in primary care, Scottish Intercollegiate Guidelines Network - SIGN (2003) Petersen I, Johnson AM, Islam A, et al; Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007 Nov 10;335(7627):982. Epub 2007 Oct 18. Tamir S, Schwartz Y, Peleg U, et al; Acute mastoiditis in children: is computed tomography always necessary? Ann Otol Rhinol Laryngol. 2009 Aug;118(8):565-9. Polat S, Aksoy E, Serin GM, et al; Incidental diagnosis of mastoiditis on MRI. Eur Arch Otorhinolaryngol. 2011 Feb 5. Jose J, Coatesworth AP, Anthony R, et al; Life threatening complications after partially treated mastoiditis. BMJ. 2003 Jul 5;327(7405):41-2. Glynn F, Osman L, Colreavy M, et al; Acute mastoiditis in children: presentation and long term consequences. J Laryngol Otol. 2008 Mar;122(3):233-7. Epub 2007 Jul 19.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions. Original Author: Dr Sean Kavanagh, Dr Michelle Wright Last Checked: 23/05/2011 Current Version: Dr Gurvinder Rull Document ID: 947 Version: 25 EMIS

http://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatments

Mastoiditis
Mastoiditis is a bacterial infection of the mastoid bone. The mastoid bone, which sits behind the ear, consists of air spaces that help drain the middle ear. When the mastoid cells become infected or inflamed, often as a result of an unresolved middle ear infection (otitis media), mastoiditis can develop. In acute mastoiditis, infection may spread outside of the mastoid bone and cause serious health complications.
Recommended Related to Ear Infection
Understanding Ear Infection -- Prevention Because bottle-fed babies are more likely to get ear infections, it is better to breast feed your infant for the first six to 12 months of life, if possible, to prevent ear infections. Remove as many environmental pollutants from your home as you can, including: Dust Cleaning fluid and solvents Tobacco smoke Also, reduce yours or your child's exposure to people with colds, and control allergies. Read the Understanding Ear Infection -- Prevention article > >

Mastoiditis typically affects children, but adults can also be affected. Some people have chronic mastoiditis, an ongoing infection of the middle ear and mastoid causing persistent drainage from the ear. Mastoiditis Causes As mentioned above, mastoiditis often develops as a result of a middle ear infection. Bacteria from the middle ear can travel into the air cells of the mastoid bone. In addition, a skin cyst (cholesteatoma) in the middle ear may block drainage of the ear, leading to mastoiditis. Mastoiditis Symptoms Mastoiditis symptoms may include: Fever, irritability, and lethargy Swelling of the ear lobe Redness and tenderness behind the ear Drainage from the ear Bulging and drooping of the ear (in acute mastoiditis)

Mastoiditis Diagnosis Any unusual ear or fever symptoms should be evaluated by a doctor. The doctor will look inside the ear with a special instrument to see if an infection is present and evaluate ear function. If mastoiditis is suspected, your doctor may recommend other tests to confirm the diagnosis, including: blood tests X-ray ear culture (removal of fluid or other substances from the ear to check for infection) If severe infection is suspected, your doctor may also recommend more in depth tests, such as a CT scan or MRI. If your doctor is concerned you may have developed meningitis as a result of mastoiditis, a lumbar puncture will be performed to test spinal fluid for infection. Mastoiditis Treatments

Chronic mastoiditis is treated with oral antibiotics, eardrops, and regular ear cleanings by a doctor. If these treatments do not work, surgery may be necessary to prevent further complications. If you or your child is diagnosed with acute mastoiditis, you may be put in the hospital to receive treatment and care by an otolaryngologist, a doctor who specializes in ear, nose, and throat disorders. Antibiotics will be given through an IV (intravenous line) to treat the infection. Surgery may also be needed to drain the fluid from the middle ear, called a myringotomy. During a myringotomy, the doctor makes a small hole in the eardrum to drain the fluid and relieve pressure from the middle ear. A small tube may be inserted into the middle ear to ventilate and prevent fluid from getting into the middle ear. Typically, the tube will fall out on its own after six to 12 months. If the infection is severe, a mastoidectomy surgical procedure may be needed to remove the infected bone behind the ear. If left untreated, mastoiditis can cause serious, even life-threatening, health complications, including hearing loss, blood clot, meningitis, or a brain abscess. But with early and appropriate antibiotic treatment, these complications can be avoided and you can recover completely. If you are prone to middle ear infections, don't let them go untreated. All bacterial ear infections should receive timely treatment with an appropriate antibiotic to prevent mastoiditis, and other serious health complications.
Further Reading:

Slideshow: Anatomy of an Ear Infection What are the symptoms of acute otitis media (middle ear infection)? All About Ear Infections Symptoms of an Ear Infection Ear Infections-Related Information Ear Infections-When To Call a Doctor Ear Problems and Injuries, Age 11 and Younger-Preparing For Your Appointment See All Baby Ear Infections Topics Top Picks

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Reviewed by Kimball Johnson, MD on September 01, 2012

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