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Mastoiditis

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Mastoiditis, Acute Mastoiditis, Chronic Mastoiditis

  • See Also
  1. Acute Otitis Media
  2. Necrotizing Otitis Externa
  • Epidemiology
  1. Rare in U.S. since the regular use of Antibiotics to treat Acute Otitis Media
  2. Historically, has been primarily a disease of children (median age 5 years)
    1. However, may occur in adults with Acute Otitis Media and Chronic Otitis Media
  • Pathophysiology
  1. Mastoid air spaces are continuous with the middle ear cavity
    1. Mastoid air cells are not fully developed until age 3 years (Mastoiditis uncommon before this age)
  2. Mastoiditis is a complication of Acute Otitis Media
    1. Extension of middle ear infection and inflammation
    2. Increased pressure destroys the mastoid septae dividing the air cells
    3. Abscess and destruction of mastoid bone
  • Risk Factors
  • Associated Conditions
  1. Acute Otitis Media extension (most common, esp. children)
  2. Chronic Otitis Media with secondary Cholesteatoma with obstruction of Ear Drainage
  3. Leukemia
  4. Mononucleosis
  5. Temporal Bone Sarcoma
  6. Kawasaki Disease
  1. Acute Otitis Media
    1. Streptococcus Pneumoniae (22-57%)
    2. Streptococcus Pyogenes (16-31%)
    3. Staphylococcus Aureus (7-15%)
    4. Haemophilus Influenzae (4-13%, likely much lower Incidence post-Hib Vaccine)
  2. Chronic Otitis Media
    1. Staphylococcus Aureus (7% overall Mastoiditis cases)
    2. Pseudomonas Aeruginosa (4% overall Mastoiditis cases)
    3. Anaerobic Bacteria
    4. Other atypical causes of Chronic Mastoiditis
      1. Nocardia
      2. Actinomyces
      3. Mycobacterium tuberculosis
  • Symptoms
  1. Severe Otalgia (81%)
  2. Fever (76%)
    1. Tmax may be >104 F
  3. Unresolved Otitis Media
  4. Hearing Loss
  5. Headache
  6. Pain at mastoid, occipital and parietal regions
  • Signs
  1. Swelling and tenderness over the mastoid process with local erythema, tenderness and fluctuance (85%)
    1. Postauricular
    2. Supraauricular
  2. Toxic appearance
  3. Inflamed and thickened TM (90% of cases)
  4. TM often perforated with Otorrhea
  • Labs
  1. Complete Blood Count (CBC)
    1. Leukocytosis
  2. Acute Phase Reactants (ESR, CRP)
    1. May be useful in monitoring disease
  3. Cultures
    1. Blood Cultures (positive in only 14% of cases)
    2. Tympanocentesis for middle ear fluid (preferred) or Auditory canal culture
  • Imaging
  1. CT of Mastoid area (MRI if intracranial spread)
  2. Fluid in the mastoid is non-specific
    1. Mastoid ear cells are contiguous with the middle ear compartment
    2. Fluid may be caused by any middle ear inflammation and is not diagnostic for masotoiditis
  3. Mastoiditis Findings
    1. Haziness or loss of mastoid air cells
    2. Periosteal thickening
    3. Subperiosteal abscess
    4. Coalescence (indication for mastoidectomy)
  4. CNS Extension Findings
    1. Cerebritis
    2. Brain Abscess
    3. Sigmoid Sinus Thrombosis
  • Differential Diagnosis
  1. See Otalgia
  2. Otitis Media
  3. Otitis Externa
  4. Necrotizing Otitis Externa
  5. Diagnosis
  6. Mastoiditis is a clinical diagnosis
    1. Normal white count and normal inflammatory markers (e.g. CRP) does NOT exclude diagnosis
    2. Lack of mastoid air cell destruction on imaging does not exclude diagnosis
  7. Types
    1. Acute Mastoiditis with periostitis
      1. Mastoid cavities with purulence but NO bony septa destruction
    2. Acute coalescent Mastoiditis (<0.01% of Acute Otitis Media cases)
      1. Mastoid cavities with purulence AND bony septa destruction
    3. Subacute or Masked Mastoiditis
      1. Persistent Mastoiditis and bony destruction
      2. Associated with untreated/recurrent or acute Otitis Media with Effusion
    4. Chronic Mastoiditis
      1. Mastoiditis over the course of months to years
  • Management
  • Acute Mastoiditis
  1. Admit for IV Antibiotics in most cases
  2. Consultations
    1. Otolaryngology Consultation
    2. Neurosurgery Consultation Indications
      1. Brain Abscess (parenchymal or epidural)
      2. Sigmoid Sinus Thrombosis
  3. CNS Involvement (e.g. Brain Abscess, cerebritis, Sigmoid Sinus Thrombosis)
    1. Consult neurosurgery, infectious disease and otolaryngology
    2. Vancomycin AND
    3. Ceftazidime AND
    4. Metronidazole
  4. Complicated Mastoiditis (chronic infection, Osteomyelitis or mastoid abscess)
    1. Consult Otolaryngology (see surgical interventions below)
    2. Piperacillin-Tazobactam (Zosyn) OR Cefepime OR Ceftazidime OR Aztreonam AND
    3. Vancomycin (Linezolid may be used as an alternative)
      1. Child: 15 mg/kg IV every 6 hours
      2. Adult: 15-20 mg/kg IV every 8-12 hours
    4. Treat for 4-6 weeks, with Antibiotics based on cultures and sensitivity
  5. Uncomplicated Mastoiditis (children with first episode)
    1. Ampicillin-Sulbactam 50 mg/kg (up to 1.5 to 3 g) IV every 6 hours OR
    2. Ceftriaxone 50-100 mg/kg/day (up to 4 g/day) divided twice daily
    3. Treat for 7-10 days, with Antibiotics based on cultures and sensitivity
  6. Otolaryngology Surgical Management
    1. Myringotomy (may be indicated in up to 30% of cases)
      1. May be indicated if mastoid septal erosions (loss of air cells) on imaging
      2. Obtain specimen for culture
      3. Tympanostomy Tubes may be placed as needed at time of procedure
    2. Mastoidectomy
      1. Indicated in subperiosteal abscess or cases refractory to Antibiotic management
      2. Removes infected bone or mucosa
  • Management
  • Chronic Mastoiditis
  1. Chronic Mastoiditis may be complicated by acute exacerbations
    1. See above for acute exacerbation Antibiotic and surgical management (complicated Mastoiditis protocol)
  2. External auditory canal measures
    1. Warm water self-irrigation of the external canal (if Tympanic Membrane intact)
    2. Topical Antibiotics (culture sensitivity directed if available)
      1. Ciprofloxacin or LevofloxacinEar Drops twice daily for 2 weeks
      2. Avoid Aminoglycoside drops (or systemic Antibiotics) due to Ototoxicity
  3. Otolaryngology Consultation
    1. Evaluate for Cholesteatoma
    2. Mastoidectomy indications
      1. Chronic drainage
      2. Osteomyelitis (e.g. Temporal Bone, petrous bone)
      3. CNS Spread of infection
  • Complications
  1. Skull Base Osteomyelitis
  2. Bacterial Meningitis
  3. Temporal Lobe epidural or Subdural Abscess
  4. Septic thrombosis of lateral venous sinus
  • References
  1. (2025) Sanford Guide, accessed on IOS 3/4/2025
  2. Bardakos, Raj and Mehta (2026) Crit Dec Emerg Med 40(2): 4-12
  3. Dumois (2020) Acute Mastoiditis Clinical Pathway, Johns Hopkins All Childrens Hospital
  4. Klein in Mandell (2000) Infectious Disease, p. 674
  5. Pfaff in Marx (2002) Rosen's Emergency Med., p. 932-3
  6. Lin (2010) Clin Pediatr 49(2):110-5 [PubMed]
  7. Loh (2018) J Laryngol 132(2): 96-104 +PMID:28879826 [PubMed]