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Mastoiditis

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Mastoiditis, Acute Mastoiditis, Chronic Mastoiditis

  • Epidemiology
  1. Rare now since the use of Antibiotics in Otitis Media
  • Pathophysiology
  1. Extension of middle ear disease
  2. 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%)
  2. Streptococcus Pyogenes (16%)
  3. Staphylococcus aureus (7%)
  4. Haemophilus Influenzae (4%, 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. Unresolved Otitis Media
  2. Hearing Loss
  3. Fever spikes may exceed 104 F
  4. Otalgia
  5. Headache
  6. Pain at mastoid, occipital and parietal regions
  • Signs
  1. Swelling and tenderness
    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. Cultures
    1. Tympanocentesis for middle ear fluid (preferred) or
    2. Auditory canal culture
  • Imaging
  1. CT of Mastoid area (MRI if intracranial spread)
  2. Findings: Loss of mastoid air cells
  • Management
  • Acute Mastoiditis
  1. Otolaryngology Consultation
  2. Admit for IV Antibiotics in most cases
  3. Uncomplicated Mastoiditis (children with first episode)
    1. Vancomycin (Linezolid may be used as an alternative)
      1. Child: 15 mg/kg IV every 6 hours
      2. Adult: 30-60 mg/kg IV divided every 8-12 hours
    2. Treat for 7-10 days, with Antibiotics based on cultures and sensitivity
  4. Complicated Mastoiditis (chronic infection, Osteomyelitis or abscess)
    1. Vancomycin (or Linezolid) AND
    2. Piperacillin-Tazobactam (Zosyn) OR Ceftazidime OR Aztreonam
    3. Treat for 4-6 weeks, with Antibiotics based on cultures and sensitivity
  5. Surgical management
    1. Myringotomy drainage or
    2. Mastoidectomy may be needed
      1. Removes infected bone or mucosa
  • Management
  • Chronic Mastoiditis
  1. 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
  2. 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. (2019) Sanford Guide, accessed on IOS 11/18/2019
  2. Klein in Mandell (2000) Infectious Disease, p. 674
  3. Pfaff in Marx (2002) Rosen's Emergency Med., p. 932-3
  4. Lin (2010) Clin Pediatr 49(2):110-5 [PubMed]
  5. Loh (2018) J Laryngol 132(2): 96-104 +PMID:28879826 [PubMed]