Mastoiditis 957.

e9

• Often, there are multiple organisms in chronic LABORATORY TESTS

BASIC INFORMATION mastoiditis, with predominance of anaerobes • Fluid for Gram stain and culture may be
and gram-negative bacteria. obtained by myringotomy.
DEFINITION • Mycobacterium tuberculosis, nontuberculous • If there is a perforation in the tympanic mem-
Mastoiditis is inflammation of the mastoid pro- mycobacteria, Aspergillus, and Rhodococcus brane with drainage, cultures of this may be
cess and air cells, a complication of otitis media. equi have been reported in cases of mastoiditis taken after carefully cleaning the external
in severely immunocompromised individuals. canal.
SYNONYM
IMAGING STUDIES
Mastoid abscess DIAGNOSIS
• Plain x-rays of the mastoid region may dem-
ICD-10CM CODES onstrate clouding or opacification in areas of
DIFFERENTIAL DIAGNOSIS
H40.1 Chronic mastoiditis pneumatization.
H70.0 Acute mastoiditis • Children: • CT scan (Fig. E1) can demonstrate early
H70.8 Other mastoiditis and related conditions 1. Rhabdomyosarcoma involvement of bone (mastoiditis with bone
H70.9 Mastoiditis, unspecified 2. Histiocytosis X destruction).
3. Leukemia • MRI is more sensitive than CT scan in evalu-
4. Kawasaki syndrome ating soft-tissue involvement and is useful in
EPIDEMIOLOGY &
• Adults: conjunction with CT scan to investigate other
DEMOGRAPHICS
1. Fulminant otitis externa complications of mastoiditis.
INCIDENCE (IN U.S.): Since the introduction of 2. Histiocytosis X
antibiotic therapy and use of broad-spectrum 3. Metastatic disease
antibiotics, there has been a marked decline in • Table E2 differentiates postauricular involve- TREATMENT
the incidence of acute mastoiditis. ment of acute mastoiditis with periostitis/
PREDOMINANT SEX: More common in males abscess. NONPHARMACOLOGIC THERAPY
PREDOMINANT AGE: 2 mo to 18 yr
Myringotomy, if the ear is not already draining
PEAK INCIDENCE: Early childhood WORKUP
A thorough history and physical examination are ACUTE GENERAL Rx
PHYSICAL FINDINGS & CLINICAL
important in establishing diagnosis. • Initiated with IV antibiotics directed against
PRESENTATION
the common organisms S. pneumoniae and
• Acute mastoiditis is usually a complication of TABLE E1  Etiology of Acute H. influenzae. Useful agents are amoxicil-
acute otitis media. Mastoiditis lin/clavulanate, ceftriaxone, and cefotaxime.
• Most common presenting symptom is pain
If the disease in the mastoid has had a
and tenderness in the postauricular region. Bacteria Frequency prolonged course, coverage for S. aureus
• Other signs or symptoms include:
Streptococcus pneumoniae 10%-51% with gram-negative enteric bacilli may be
1. Fever
Streptococcus pyogenes 0%-12% considered for initial therapy until results of
2. Postauricular erythema and edema
Staphylococcus aureus 2%-10% cultures become available. Add vancomycin
3.  Protrusion of the pinna inferiorly and
if methicillin-resistant Staphylococcus aure-
anteriorly Pseudomonas aeruginosa 10%
us (MRSA) suspected or nafcillin/oxacillin if
4. Tympanic membrane usually intact with Haemophilus influenzae 2%-3%
culture is positive for S. aureus, methicillin
signs of acute otitis media No growth 20%-40% susceptible.
• Complications of acute mastoiditis include:
• Antibiotics continued until all signs of mas-
1.  Subperiosteal abscess (most common From Kliegman RM: Nelson textbook of pediatrics, ed 21,
Philadelphia, 2020, Elsevier. toiditis have resolved.
complication)
2. Hearing loss
3. Facial nerve palsy
4. Labyrinthitis
5. Intracranial complications such as hydro-
TABLE E2  Differential Diagnosis of Postauricular Involvement of Acute
cephalus, meningitis, encephalitis, intracra-
nial abscess, and lateral sinus thrombosis Mastoiditis with Periostitis/Abscess

• 
Chronic mastoiditis is characterized by Postauricular Signs and Symptoms External Middle-
chronic otorrhea and chronic tympanic mem- Canal Ear
brane perforation. Disease Crease* Erythema Mass Tenderness Infection Effusion
ETIOLOGY Acute mastoiditis with May be Yes No Usually No Usually
• Continuity exists between the middle air periostitis absent
space and the mastoid cavity. Acute mastoiditis Absent Maybe Yes Yes No Usually
• Initial hyperemia and edema of the mucosal with subperiosteal
abscess
lining of the air cells result in accumulation of
purulent exudate. Periostitis of pinna Intact Yes No Usually No No
with postauricular
• Dissolution of calcium from bony septa and extension
osteoclastic activity in the inflamed perios-
External otitis with Intact Yes No Usually Yes No
teum lead to bone necrosis and coalescence postauricular
of air cells. extension
• Most common bacterial isolates (Table E1) are: Postauricular Intact No Yes† Maybe No No
1.  Streptococcus pneumoniae lymphadenitis
2.  Streptococcus pyogenes
3.  Haemophilus influenzae *Postauricular crease (fold) between pinna and postauricular area.
†Circumscribed.
4.  Moraxella catarrhalis
From Bluestone CD, Klein JO (eds): Otitis media in infants and children, ed 3, Philadelphia, 2001, Saunders, p 333. In Kliegman RM:
5.  Staphylococcus aureus Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.

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957.e10 Mastoiditis

A B C
FIG. E1  This contrasted CT scan shows coalescent mastoiditis with subperiosteal abscess formation. Panels A and B contain axial images with soft tis-
sue windows and bone windows, respectively. In panel A, the arrow points to the subperiosteal abscess. The star in panel B shows the loss of bony septations in the
mastoid cavity and the arrow points to the erosion of the bony cortex. Panel C is a coronal image showing demineralization of the mastoid tegmen abutting the middle
cranial fossa. The image in panel C is a precursor to epidural abscess formation. (From Kliegman RM: Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.)

• Directed against enteric gram-negative organ- REFERRAL

isms and anaerobes in chronic mastoiditis.
• Indications for mastoidectomy:
1. Failure to improve after 72 hr of therapy
2. Persistent fever
3. Imminent or overt signs of intracranial
complications
4. Evidence of a subperiosteal abscess in
the mastoid bone
DISPOSITION
Proceed with mastoidectomy when medical
therapy fails.
• To otorhinolaryngologist:
PEARLS &
1. If diagnosis is in doubt CONSIDERATIONS
2. If aural complications present
Mastoiditis is particularly difficult to eradicate
3. To evaluate for surgical intervention
because the mastoid air cells are poorly vascu-
• To neurosurgeon if intratemporal or intracra-
larized and difficult to drain.
nial extension of infection suspected:
1.  Aural complications: Bone destruction, RELATED CONTENT
subperiosteal abscess, petrositis, facial
Mastoiditis (Patient Information)
paralysis, labyrinthitis
2.  Intracranial complications: Extradural AUTHOR: Glenn G. Fort, MD, MPH
abscess, lateral sinus thrombophlebitis or
thrombosis, subdural abscess, meningitis,
brain abscess, otitic hydrocephalus

SUGGESTED READINGS
Bunik M: Mastoiditis, Pediatr Rev 35:94-95, 2014.
Chesney J et al: What is the best practice for acute mastoiditis in children?
Laryngoscope 124(5):1057-1058, 2014.
Lin HW et al: Clinical strategies for the management of acute mastoiditis in the
pediatric population, Clin Pediatr 49(2):110-115, 2010.
Loh R: Management of pediatric acute mastoiditis: systematic review, J Laryngol
Otol 132:96-104, 2018.

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on September 19, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.