Mastoiditis

The term mastoiditis is used when infection spreads from the mucosa, lining the mastoid air cells, to involve bony walls of the mastoid air cell system.

Aetiology
Usually accompanies suppurative ottitis media Determining factors High virulence of organism Lowered resistance of the patient Children are affected more Beta hemolytic streptococcus is the most common cause

Pathology
Two main pathological processes are responsible Production of pus under tension Hyperemic decalcification and osteoclastic resorption of bony walls

Pathology (cont)
Inflammation of mucoperiosteal lining air cell system increasing the pus production The large amount of pus caanot be drained efficiently through small perforation of tympanic membrane or eusthacian tube Swollen mucosa of the antrum and attic also impede the drainage system resulting in accumulation of pus under tension

Pathology (cont)
Hyperemia and engorgement of mucosa causes dissolution of calcium from bony walls of the mastoid air cells Both of these processes combine to cause destruction and coalescence of mastoid air cells, converting them into Pus may break through mastoid cortex leading to sub-periosteal abscess which may burst into discharging fistula

Clinical features
Symptoms Pain behind the ear Persistence of pain, increase in intensity or recurrence of pain after treatment of acute otitis media are significant pointers Fever Persistence and recurrence of fever in a case of acute otitis media in spite of adequate antibiotic treatment

Symptoms
Ear discharge Discharge becomes profuse and increases in purulence Discharge may cease due to obstruction Any persistence of discharge beyond 3 weeks

Signs
Mastoid tenderness Tenderness is elicited over the middle of mastoid process, at its tip, posterior border or root of zygoma. Ear discharge Mucopurulent or purulent discharge, often pulsatile, may seen coming through central perforation of pars tensa

Signs (cont)
Sagging of posterior meatal wall
Due periosteitis of bony part of wall between antrum and deeper posteriosuperior part of bony canal

Perforation of tympanic membrane

Usually a small perforation seen in pars tensa with congestion of the rest of tympanic membrane or sometimes may appear as a nipple like protrusion

Signs (cont)
Swelling over the mastoid
Initially there is edema of periosteum giving an ironed out feeling to the mastoid Later retroauricular sulcus becomes obliterated and pinna is pushed forward and downward When the pus bursts through bony cortex a periosteal fluctuant abscess is formed

Signs (cont)
Hearing loss
Conductive type

General findings
Patient appears ill and toxic with low grade fever In children the fever is high with a rise in pulse rate

Investigations
Blood count Polymorphonuclear leucocytosis ESR- raised X-ray mastoid There is clouding of the air cells due to collection of exudate in them Bony partitions between the cells become indistinct In later stages a cavity may be seen in the mastoid

Differential diagnosis
Suppuration of mastoid lymph nodes Furunculosis of meatus Infected sebaceous cyst

Treatment
Hospitalization of the patient Antibiotics
Start with amoxicillin or ampicillin Specific antimicrobial is started on receipt of sensitivity report Usually chloramphenicol or metronidazole is added

Treatment (cont)
Myringotomy
When pus is under tension it is relieved by wide myringotomy

Treatment (cont)
Cortical mastoidectomy
Indication
Subperiosteal absc Sagging of posteriosuperior meatal wall Positive reservoir sign No change in condition of the patient or it worsens inspite of acute medical tresatment for 48 hours Mastoiditis leading to complications

Treatment (cont)
The aim of mastoidectomy is to externate all the mastoid air cells and remove any pockets of pus. Adequate antibiotic treatment must be continued atleast for 5 days following mastoidectomy

Complications of acute mastoiditis

Subperiosteal abscess Labrinthytis Facial paralysis Petrositis Extradural abcess Meningitis Brain abscess Laterla sinus thrombophlebitis Otitic hyrocephalus

Abscess in relation to mastoid infection

Postauricular abscess
Commones abscess formed over the mastoid Pinna is displaced forwards outwards and downwards Pus travels along vascular channels of lamina cribosa

Zygomatic abscess
Occurs due to infection of zygomatic air cells situated at the posterior part of zygoma Swellings appear in front and above the pinna, edema of upper eye lid Pus collects either superficial or deep to temporalis muscle

 Bezold abscess
It can occur following acute coalescent mastoiditis Presents as a swelling in the upper part of neck The abscess may
Lie deep to sternocledomastoid Follow the posterior belly of digastric and present as swelling between tip of mastoid and angle of jaw Present in upper part of posterior triangle Reach the parapharyngeal space Track down along the carotid vessels

 Meatal abscess (Lucs abscess)

Pus breaks through bony wall and external osseus meatus Swelling is seen in deep part of bony meatus Abscess may burst into meatus

Behind the mastoid (Citellis abscess)

Formed behind the mastoid more towards the occipital bone

 Parapharyngeal or retro pharyngeal abscess

This results from infection of peritubal cells due to acute coalescent mastoiditis