• Epidemiology
  1. Rare since the regular use of Antibiotics to treat Acute Otitis Media
  • Pathophysiology
  1. Mastoid air spaces are continuous with the middle ear cavity
  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
  • Predisposing factors
  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. 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)
  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. Mastoiditis Findings
    1. Haziness or loss of mastoid air cells
    2. Periosteal thickening
    3. Subperiosteal abscess
  3. CNS Extension Findings
    1. Cerebritis
    2. Brain Abscess
    3. Sigmoid Sinus Thrombosis
  4. Diagnosis
  5. 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
  • Management
  • Acute Mastoiditis
  1. Admit for IV Antibiotics in most cases
  2. Consultations
    1. Otolaryngology Consultation (most cases)
    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
      1. May be indicated if mastoid septal erosions (loss of air cells) on imaging
      2. Obtain specimen for culture
    2. Mastoidectomy
      1. Indicated in subperiosteal abscess
      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. 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. Dumois (2020) Acute Mastoiditis Clinical Pathway, Johns Hopkins All Childrens Hospital
  3. Klein in Mandell (2000) Infectious Disease, p. 674
  4. Pfaff in Marx (2002) Rosen's Emergency Med., p. 932-3
  5. Lin (2010) Clin Pediatr 49(2):110-5 [PubMed]
  6. Loh (2018) J Laryngol 132(2): 96-104 +PMID:28879826 [PubMed]