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Acute Mastoiditis

Acute mastoiditis (AM) is characterized by an inflammation of the mastoid air cells of the temporal bone and is likely a consequence of acute otitis media. Most common infections involve Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. The surgical treatment option usually provides the best recovery perspectives, if broad-spectrum antibiotics haven't alleviated symptoms.

Presentation

Acute mastoiditis (AM) is the most probable complication of acute otitis media [1]. In more than fifty percent of diagnosed patients, it is the first evident manifestation of acute otitis media [2] [3] [4]. AM is caused by bacterial infection and can overshadow other conditions or develop into a chronic form.

AM typically presents with mastoid area erythema, proptosis of the auricle, fever, otorrhea, lethargy and pain. Fever may be quite high. Pain is located deep in or behind the ear and is usually worse at night. Persisting pain is an indication of a more serious condition of the mastoid. Hearing loss is frequently reported in AM and should recover back to normal after the infection has worn off [5].

If left untreated, AM can pave the way for severe complications like sigmoid sinus thrombosis, brain abscess, facial paralysis, otitic hydrocephalus, and in rare cases to Bezold's abscess [6].

The infection of the mastoid bone is most likely caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, less probably by group A Streptococci, Staphylococcus aureus, and the Pseudomonas species. The mean gap time between infection and onset of AM is 4.5 days [7].

AM is more likely in children than in adults. Risk factors include a recent untreated bacterial infection of the middle ear and cholesteatoma. In infants, it is advisable to look out for general symptoms that may be consistent with infections like diarrhea, irritability, or malnutrition [3].

Entire Body System

Fever

AM typically presents with mastoid area erythema, proptosis of the auricle, fever, otorrhea, lethargy and pain. Fever may be quite high. Pain is located deep in or behind the ear and is usually worse at night.[symptoma.com]
The findings of fever, pain, postauricular swelling, and otorrhea are classic. Cholesteatoma, on the other hand, being associated with chronic infection, usually occurs in the sclerotic temporal bone.[ncbi.nlm.nih.gov]
A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve.[ncbi.nlm.nih.gov]
RESULTS: One hundred and thirty-four children (143 episodes) with acute mastoiditis were identified during 2008-2009; 81% had fever, 95% auricular displacement, and 80% post-auricular swelling.[ncbi.nlm.nih.gov]
In periods one, two and three, respectively: mean annual case load was 8.4, 5 and 9 children; pneumococcal isolates were seen in 40.5, 6.7 and 29.6 per cent of cases; highest recorded fever was 38.6, 38.9 and 38.2 C and highest leukocyte count 18.9, 15.0[ncbi.nlm.nih.gov]

Malaise

Acute mastoiditis is a serious complication of AOM in childhood with postauricular swelling, erythema, and tenderness, protrusion of the auricle, high fever and general malaise. The disease may protrude intracranially.[ncbi.nlm.nih.gov]
There is also fever and malaise. The pain intensifies if the affected area is touched. There is clear swelling behind the ear, and the skin is red.[ic.steadyhealth.com]
Symptoms of acute mastoiditis: 1) Fever and malaise: Fever is persistent, in spite of adequate antibiotics. It can be as high as 40 degree C 2) Pain: It is usually post-aural.[specialist-ent.com]
Diagnosis The most common systemic signs and symptoms associated with acute mastoiditis include lethargy, malaise or irritability, fever, and poor feeding.[epmonthly.com]

Ears

Otalgia

A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve.[ncbi.nlm.nih.gov]
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. Copyright 2014 Elsevier Ireland Ltd. All rights reserved.[ncbi.nlm.nih.gov]
Otalgia, fever, poor feeding and vomiting were the most common symptoms, all the children had evidence of retroauricolar inflammation.[ncbi.nlm.nih.gov]
Most common symptom was otalgia (84%), 58% of patients had history of past AOM and 61% were under antibiotic therapy during admission. Twenty-three patients (74%) presented retroauricular swelling and erythema. 18 (58%) had a displaced pinna.[ncbi.nlm.nih.gov]
Younger age (less than two years old), male sex, prior antimicrobial therapy, absence of otalgia were more common in complicated cases (p 0,05).[revistas.rcaap.pt]

Ear Discharge

Cultures were obtained at admission in 83 (72%) episodes (71 by tympanocentesis and 12 from ear discharges). Overall 43 pathogens were isolated: 34 at admission; 14 at surgery; and 5 at both occasions.[ncbi.nlm.nih.gov]
NIH: National Institute on Deafness and Other Communication Disorders Cholesteatoma (Medical Encyclopedia) Ear discharge (Medical Encyclopedia) Ear examination (Medical Encyclopedia) Ear infection - acute (Medical Encyclopedia) Ear infection - chronic[icdlist.com]
In particular, Pseudomonas aeuriginosas was isolated in 3 patients from spontaneous ear discharge.[link.springer.com]
The presence of unilateral headache is suggestive of impending intracranial complications 3) Ear discharge: The discharge is purulent, profuse and foul smelling.[specialist-ent.com]
It is symptomatic with persistent ear discharge, deep eye pain, and diplopia due to paresis of cranial nerve VI.[rrnursingschool.biz]

Workup

The diagnosis of AM is based on patient history and clinical examination. There is no well-defined consensus which symptoms are crucial in diagnosing AM.

It is usually not necessary to go beyond the clinical diagnosis but it may be advisable to consider computed tomography (CT) or magnetic resonance imaging (MRI) of the temporal bone as a possibility to better assess the extent of the infection and screen for other possible reasons of the inflammation. Some experts consider CT scan a necessary procedure in AM diagnosis [8]. Both in CT and MRI, AM presents with a partial to total opacification of the mastoid air cells.

If ear drainage occurs, it is highly advisable to analyze the material for cultures, Gram stain, and acid-fast stain. If there is no spontaneous drainage, ear fluid could be obtained within a tympanocentesis and/or myringotomy procedure. The tympanic membrane will recover fast and extraction of excess ear fluid will likely ease acute symptoms. It is often possible to carry out both procedures in one session without additional discomfort for the patient. Tympanostomy tube insertion is often performed to allow for continued drainage and easier administration of antimicrobial agents [9].

An audiometric test should be scheduled after complete recovery.

Treatment

Higher rate of recurrent AOM was noted in the immediate compared with delayed antibiotic treatment group (29% vs. 8.7%, P 0.0021).[ncbi.nlm.nih.gov]
CONCLUSION: Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy[ncbi.nlm.nih.gov]
Intracranial complications in children resulted from unsuccessful treatment of AOM, which led to acute mastoiditis and lateral sinus thrombosis.[ncbi.nlm.nih.gov]
SUMMARY: Antibiotic therapy and myringotomy with ventilation tube placement, with or without mastoidectomy, are the mainstays of treatment for intracranial complications of acute mastoiditis.[ncbi.nlm.nih.gov]
The aim of this study was to map the occurrence, treatment policy and the clinical course of mastoiditis before and after the new treatment recommendations were introduced.[ncbi.nlm.nih.gov]

Prognosis

[…] diffusion restriction 5 Signal characteristics Typical findings in mastoiditis include 4,5 : T1 : low signal T2 : high signal DWI/ADC : diffusion restriction may be present T1 C : mucosal contrast enhancement is present in the majority Treatment and prognosis[radiopaedia.org]
Prognosis The prognosis for the vast majority of cases that are diagnosed early is excellent with a low chance of complications or severe hearing loss.[patient.info]
The prognosis of mastoiditis depends on the extent of the infection. Fortunately, if detected early prior to intracranial involvement, the prognosis is very good.[hawaii.edu]
If there are complications, or the mastoiditis does not respond to the above treatments, it may be necessary to perform a mastoidectomy : a procedure in which a portion of the bone is removed and the infection drained. [4] Prognosis [ edit ] With prompt[en.wikipedia.org]

Etiology

Moraxella catarrhalis (M. catarrhalis) is the third most common bacteria found in acute otitis media, and in recent years its importance as an etiological factor of acute otitis media has markedly increased in certain geographic areas.[ncbi.nlm.nih.gov]
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
Bacterial etiology was established in 43 patients (68.2% isolation rate). Pseudomonas aeruginosa and Streptococcus pneumoniae were the most frequently isolated agents.[ncbi.nlm.nih.gov]
Etiological agents were Streptococcus pneumoniae (28.5%) and Staphylococcus aureus (16.3%). Negative cultures were obtained in 53.6% of cases.[ncbi.nlm.nih.gov]
CONCLUSIONS: (1) AM occurs frequently in patients without previous AOM history and with no previous antibiotic treatment; (2) S. pneumoniae and S. pyogenes continued to be the main etiologic agents of AM during the postvaccination period; (3) No changes[ncbi.nlm.nih.gov]

Epidemiology

A retrospective review of children discharged with a diagnosis of acute mastoiditis was undertaken to describe the epidemiology, clinical presentation, microbiology, and treatment of acute mastoiditis over past years.[ncbi.nlm.nih.gov]
OBJECTIVES: To describe the epidemiologic, microbiologic, clinical and therapeutic aspects of acute mastoiditis (AM) in children PATIENTS AND METHODS: The medical records of all children with a discharge diagnosis of AM were reviewed.[ncbi.nlm.nih.gov]
There exists no epidemiological data on acute mastoiditis in the Arctic region.[ncbi.nlm.nih.gov]
Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clinical Pediatrics ;43:261 -7. Kvaerner KJ. Lessons learned: no increase despite clinical of acute mastoiditis.[revistas.rcaap.pt]
Ingvarssom L, Lundgren K, Olofsson B (1985) Epidemiology of acute otitis media in children in an urban population. Auris Nasus Larynx 1(Suppl 12):105–107 Google Scholar 8.[link.springer.com]

Sex distribution

Age distribution

Pathophysiology

This review presents an overview of the anatomical and pathophysiological considerations in acute mastoiditis and offers pediatricians a practical, evidence-based algorithm for the diagnostic and therapeutic approach to this disease.[ncbi.nlm.nih.gov]
The differences between age groups suggest that there are distinctions in the pathophysiology behind the onset and course of acute mastoiditis in younger and older children. Copyright 2012 Elsevier Ireland Ltd. All rights reserved.[ncbi.nlm.nih.gov]
Author information 1 Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy.[ncbi.nlm.nih.gov]
The pathophysiology and symptoms of the disease are described and in showing the case our way of solving complications is described.[hrcak.srce.hr]
Drainage from the ear occurs in more serious cases, often manifest as brown discharge on the pillowcase upon waking. [4] [5] Pathophysiology [ edit ] The pathophysiology of mastoiditis is straightforward: bacteria spread from the middle ear to the mastoid[en.wikipedia.org]

Prevention

We report one case of acute mastoiditis with epidural abscess, in which mastoidectomy with tympanic exploration was needed to ensure drainage throughout the cavities and to prevent pressure rebuilding in the mastoid and tympanic cavities.[ncbi.nlm.nih.gov]
Great care is required from clinicians to make an early diagnosis in order to promote adequate management and prevent complications.[ncbi.nlm.nih.gov]
Acute mastoiditis is a potentially life-threatening disease, but the timely administration of intravenous antibiotics and surgical intervention prevented the occurrence of severe complications in these young infants.[ncbi.nlm.nih.gov]
Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]

References

Article

Minovi A, Dazert S. Diseases of the middle ear in childhood. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2014;13:Doc11.
Bluestone CD, Klein JO. Intratemporal complications and sequelae of otitis media. In: Bluestone CD, Casselbrant ML, Stool SE et al eds. Pediatric otolaryngology. 4th ed. Philadelphia, PA: Saunders; 2003:687.
Bahadori RS, Schwartz RH, Ziai M. Acute mastoiditis in children: an increase in frequency in Northern Virginia. Pediatr Infect Dis J. 2000;19:212-215.
Geva A, Oestreicher-Kedem Y, Fishman G, et al. Conservative management of acute mastoiditis in children. Int J Pediatr Otorhinolaryngol. 2008;72:629-634.
van den Aardweg MT, Rovers MM, de Ru JA, Albers FW, Schilder AG. A systematic review of diagnostic criteria for acute mastoiditis in children. Otol Neurotol. 2008;29(6):751-757.
Lazim NM, Abdullah A. An Extensive Cholesteatoma with Bezold’s Abscess. International Journal of Clinical Medicine. 2011;2:292-294.
Oestreicher-Kedem Y, Raveh E, Kornreich L, Popovtzer A, Buller N, Nageris B. Complications of mastoiditis in children at the onset of a new millennium. Ann Otol Rhinol Laryngol. 2005;114(2):147-152.
Saat R, Laulajainen-Hongisto AH, Mahmood G et al. MR imaging features of acute mastoiditis and their clinical relevance. AJNR Am J Neuroradiol. 2014;36(2):361-367.
Abdel-Aziz M, El-Hoshy H. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. BMC Ear, Nose and Throat Disorders. 2010;10:1.

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Last updated: 2019-06-28 11:53