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].

• 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]

  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]

  Case Two: A 23-month-old female presents to the emergency department with five days of fever, cheek swelling, and not allowing family to touch her face or ears. She was seen three days prior with complaints of fever and left ear pain... [epmonthly.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]

• 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]

• Poor Feeding

  Otalgia, fever, poor feeding and vomiting were the most common symptoms, all the children had evidence of retroauricolar inflammation. [ncbi.nlm.nih.gov]

  Diagnosis The most common systemic signs and symptoms associated with acute mastoiditis include lethargy, malaise or irritability, fever, and poor feeding. [epmonthly.com]

• Protein S Deficiency

  Hypercoagulable states, inherited (antithrombin III, protein C or protein S deficiency, factor V Leiden mutation or prothrombin gene 20210A mutation) or acquired (neoplasms, trauma, autoimmune disorders, neurosurgical interventions, myeloproliferative [ncbi.nlm.nih.gov]

• 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]

  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]

  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]

  In particular, Pseudomonas aeuriginosas was isolated in 3 patients from spontaneous ear discharge. [link.springer.com]

  It is symptomatic with persistent ear discharge, deep eye pain, and diplopia due to paresis of cranial nerve VI. [rrnursingschool.biz]

• Tinnitus

  […] dysfxn presentation and defintion Often follows URI or allergic rhinitis Eustachian tube swelling inhibits eustachian tube's ability to autoinsufflate Negative pressure eustachian tube dysfxn sxs and dx Sxs- ear fullness, popping, underwater feeling, tinnitus [quizlet.com]

  } Chronic Ear Infection (Mastoiditis), Auto immune disease, Tinnitus, Hot Flushes, Weight Loss – Kangen Water Testimonial Health Benefits Drinking … Health … [pinterest.co.uk]

  Please advise me if any thing could be done to get rid of tinnitus. [doctor.ndtv.com]

  Bell’s Palsy (early) Before the nerve is paralyzed, patients will often report sharp pain or tinnitus. Foreign bodies Always inspect the ear and look for them. Temporal arteritis Elderly; temporal tenderness. [hippoed.com]

  […] other symptoms and after-effects that point to a otitis media acuta: Feeling of weakness Redness and swelling of the mastoid process Sensation of pressure and fullness in the ear Dizziness Fever Headache Conductive hearing loss Ringing in the ears (tinnitus [hear.com]

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.

1. Minovi A, Dazert S. Diseases of the middle ear in childhood. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2014;13:Doc11.
2. 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.
3. 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.
4. Geva A, Oestreicher-Kedem Y, Fishman G, et al. Conservative management of acute mastoiditis in children. Int J Pediatr Otorhinolaryngol. 2008;72:629-634.
5. 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.
6. Lazim NM, Abdullah A. An Extensive Cholesteatoma with Bezold’s Abscess. International Journal of Clinical Medicine. 2011;2:292-294.
7. 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.
8. 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.
9. 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.