JIMS HOMOEOPATHIC MEDICAL
COLLEGE AND HOSPITAL ACUTE MASTOIDITIS:
DEPARTMENT OF PAEDIATRICS
TOPIC: MASTOIDITIS
DATE: 2-05-2024, THRUSDAY
PRESENTER:
DR. FATIHA SULTANA SABA
MD-PART-II
MODERATOR:
DR. M RAMYA KRISHNA
ASST. PROF DEPT OF PAEDIATRICS
JIMSHMCH
MASTOIDITIS
Inflammation of mucosal lining of antrum
and mastoid air cell system is an invariable
accompaniment of acute otitis media and forms a
part of it.1
The term “mastoiditis” is used when
infection spreads from the mucosa, lining the
mastoid air cells, to involve bony walls of the
mastoid air cell system.1,2
INCIDENCE:
 Acute mastoiditis represents the most common
complication of an AOM, affecting 1 in 400
cases (0.24%).3
 Its incidence is variously reported in different
countries, varying in pediatric age from 1.2 to
6.1 per 100,000 children aged 0-14 years, per
year. 3
 Dramatically decreased in the antibiotic era,
the incidence of Acute mastoiditis in pediatric
age has consistently increased in the last two
decades even in developed countries. 3
 Pediatric age is undoubtedly the most prone to
mastoid involvement in middle ear infections,
due to particular anatomical, immunological
and infectious conditions.
 Above all in the first years of life: In children,
the mastoid bone is more pneumatized with
thin bone trabeculae and the aditus and antrum
is smaller than in adult’s: so, there is a greater
predisposition to the accumulation of secretion
and osteitic infection. 3
 Pediatric age is often characterized by
physiological immaturity of the immune
system with a peak incidence between the
second and third year of life. 3
 Most children (27 observed from 2003 to
2017) were < 3 years old; just one case was >
10 years old.3
AETIOLOGY:
Acute mastoiditis is often seen in mastoids
with well-developed air cell system. Children are
affected more. 1
Factors leading to acute mastoiditis:
(i) Inadequate drainage: If the exudate is not
draining well, infection may spread to the
mastoid.1,2
(ii) Virulence of organisms: The infection may
spread if the organisms are virulent. 1,2
(iii) Lowered resistance of the patient because of
diseases like exanthemata, dehydration and
diabetes may also be responsible. 1,2
(iv) Cellular mastoids are more likely to be
involved. 2
(v) Poor nutrition.1
(vi) Associated systemic disease such as diabetes.
(vii) Inadequate or improper treatment of acute
otitis media fail to control the infection, and the
infection may spread or become masked. 2
 Beta-haemolytic streptococcus is the most
common causative organism though other
organisms responsible for acute otitis media
may also be seen. 1
 Cellular mastoid when affected by otitis media
may lead to 2 stages of mastoiditis:
(a) Catarrhal mastoiditis.
(b) Coalescent mastoiditis.
 These usually occur in the second or third
week. 2
 Chronic otitis media produces chronic
mastoiditis, usually in a sclerotic bone.2
(A) CATARRHAL MASTOIDITIS
It follows the stage of suppuration in acute
suppurative otitis media. In this stage, there is
congestion of the mucosa of the mastoid, which
leads to aggravation of symptoms. 2
(B) COALESCENT MASTOIDITIS
Due to the spread of infection,
granulations and oedema develop, and they block
partially or totally the aditus to the antrum. The
pus collects in the mastoid cavity under pressure
with the break-down of the septa between the air
cells. The air cells in the mastoid coalesce and the
mastoid cavity becomes converted into a bag of
pus (empyema).
PATHOLOGY:
Two main pathological processes are responsible:
1. Production of pus under tension.
2.Hyperaemic decalcification and osteoclastic
resorption of bony walls.
 Extension of inflammatory process to
mucoperiosteal lining of air cell system
increases the amount of pus produced due to
large surface area involved.1
 Drainage of this pus, through a small
perforation of tympanic membrane and/or
eustachian tube, cannot keep pace with the
amount being produced. 1
 Swollen mucosa of the antrum and attic also
impede the drainage system resulting in
accumulation of pus under tension. 1
 Hyperaemia and engorgement of mucosa
causes dissolution of calcium from the bony
walls of the mastoid air cells (hyperaemic
decalcification). 1
 Both these processes combine to cause
destruction and coalescence of mastoid air
cells, converting them into a single irregular
cavity filled with pus (empyema of mastoid). 1
 Pus may break through mastoid cortex leading
to subperiosteal abscess which may even burst
on surface leading to a discharging fistula. 1
CLINICAL FEATURES:
Symptoms:
They are similar to that of acute
suppurative otitis media. In a case of acute middle
ear infection, it is the change in the character of
these symptoms which is significant and a pointer
to the development of acute mastoiditis.
1. Pain behind the ear. Pain is seen in acute otitis
media but it subsides with establishment of
perforation or treatment with antibiotics. It is the
persistence of pain, increase in its intensity or
recurrence of pain, once it had subsided. These are
significant pointers of pain. Severe and boring in
character.1,2
2. Fever. It is the persistence or recurrence of
fever in a case of acute otitis media, in spite of
adequate treatment that points to the development
of mastoiditis.
3. Ear discharge. In mastoiditis, discharge
becomes profuse and increases in purulence. In
some cases, discharge may cease due to
obstruction to its drainage but other symptoms
would worsen. Any persistence of discharge
beyond 3 weeks, in a case of acute otitis media,
points to mastoiditis.
Signs
 Mastoid tenderness.
 Ear discharge.
 Sagging of posterosuperior meatal wall
 Perforation of tympanic membrane.
 Swelling over the mastoid.
 Hearing loss. Conductive type of hearing loss
is always present.
 General findings. Patient appears ill and toxic
with low-grade fever. In children, fever is high
with a rise in pulse rate.
(2) CHRONIC MASTOIDITIS
This occurs with chronic suppurative otitis
media. While benign chronic otitis media may
produce scanty granulations in the mastoid,
dangerous chronic otitis media with cholesteatoma
may erode the mastoid bone gradually, and the
mastoid becomes filled with cholesteatoma and
granulations. This happens usually in acellular
mastoids. 1
Acute mastoiditis may be superimposed on
chronic mastoiditis. Features of chronic
suppurative otitis media are also present. 1
Investigations
1.Blood Counts show polymorphonuclear
leucocytosis. 1
2.Erythrocyte Sedimentation Rate is usually
raised.
3.X-Ray Mastoid. CT scan temporal bone. There
is clouding of air cells due to collection of exudate
in them. Bony partitions between air cells become
indistinct, but the sinus plate is seen as a distinct
outline. In later stages, a cavity may be seen in the
mastoid.
4. Ear Swab. for culture and sensitivity.
Differential Diagnosis
1.Suppuration of Mastoid Lymph Nodes.
Scalp infection may cause mastoid lymph
node enlargement an then suppuration leading to
abscess formation, but in such cases there is no
history of preceding otitis media, ear discharge or
deafness. Abscess is usually superficial.
2. Furunculosis of Meatus.
 It is differentiated from acute mastoiditis
by:
(a) Absence of preceding acute otitis media.
(b) Painful movements of pinna; pressure over the Abscesses in Relation to Mastoid Infection
tragus or below the cartilaginous part of meatus Postauricular Abscess:
causes excruciating pain. This is the commonest abscess that forms
(c) Swelling of meatus is confined to the over the mastoid. Pinna is displaced forwards,
cartilaginous part only. outwards and downwards. In infants and children,
(d) Discharge is never mucoid or mucopurulent. abscess forms over the MacEwen’s triangle; pus
Mucoid element in discharge can only come from in these cases travels along the vascular channels
the middle ear and not from the external ear which of lamina cribrosa.
is devoid of mucus-secreting glands. Zygomatic Abscess:
(e) Enlargement of pre- or postauricular lymph It occurs due to infection of zygomatic air
nodes. cells situated at the posterior root of zygoma.
(f) Conductive hearing loss is usually mild and is Swelling appears in front of and above the. There
due to the occlusion of meatus. is associated oedema of the upper eyelid. In these
(g) An absolutely normal looking tympanic cases, pus collects either superficial or deep to the
membrane excludes possibility of acute temporalis muscle.
mastoiditis. Bezold Abscess.
(h) X-ray mastoid with clear air-cell system It can occur following acute coalescent
excludes acute mastoiditis. Sometimes, difficulty mastoiditis when pus breaks through the thin
arises when air-cell system appears hazy due to medial side of the tip of the mastoid and presents
superimposed soft tissue swelling in cases of as a swelling in the upper part of neck. The
furunculosis. abscess may
3. Infected Sebaceous Cyst (i) lie deep to sternocleidomastoid, pushing the
muscle outwards,
Complications of Acute Mastoiditis (ii) follow the posterior belly of digastric and
1. Subperiosteal abscess present as a swelling between the tip of mastoid
2. Labyrinthitis and angle of jaw,
3. Facial paralysis (iii) be present in upper part of posterior triangle,
4. Petrositis (iv) reach the parapharyngeal space or
5. Extradural abscess (v) track down along the carotid vessels.
6. Subdural abscess Clinical features.
7. Meningitis Onset is sudden. There is pain, fever, a
8. Brain abscess tender swelling in the neck and torticollis. Patient
9. Lateral sinus thrombophlebitis gives history of purulent otorrhoea.
10. Otitic hydrocephalous. A Bezold abscess should be differentiated from:
(a) acute upper jugular lymphadenitis.
(b) abscess or a mass in the lower part of the
parotid gland.
(c) an infected branchial cyst.
(d) parapharyngeal abscess.
(e) jugular vein thrombosis.
A computed tomography (CT) scan of the
mastoid and swelling of the neck may establish
the diagnosis.
Meatal Abscess (Luc Abscess):
In this case, pus breaks through the bony
wall between the antrum and external osseous
meatus. Swelling is seen in deep part of bony
meatus. Abscess may burst into the meatus.
Behind the Mastoid (Citelli’s Abscess):
Abscess is formed behind the mastoid
more towards the occipital bone (compare
postauricular mastoid abscess which forms over
the mastoid). Some authors consider abscess of
the digastric triangle, which is formed by tracking
of pus from the mastoid tip, as the Citelli’s
abscess.
Parapharyngeal or Retropharyngeal Abscess.
This results from infection of the peri tubal
cells due to acute coalescent mastoiditis.
MASKED (LATENT) MASTOIDITIS:
It is a condition of slow destruction of
mastoid air cells but without the acute signs and
symptoms often seen in acute mastoiditis. 1
There is no pain, no discharge, no fever and no
mastoid swelling but mastoidectomy may show
extensive destruction of the air cells with
granulation tissue and dark gelatinous material
filling the mastoid.
It is not surprising to find erosion of the tegmen
tympani and sinus plate with an extradural or
perisinus abscess.
Aetiology:
The condition often results from inadequate
antibiotic therapy in terms of dose, frequency and
duration of administration.
Most often it results from use of oral penicillin
given in cases of acute otitis media when acute
symptoms subside but smouldering infection
continues in the mastoid.
Clinical Features:
 Patient is often a child, not entirely feeling
well, with mild pain behind the ear but with
persistent hearing loss.
 Tympanic membrane appears thick with loss
of translucency.
 Slight tenderness may be elicited over the
mastoid.
 Audiometry shows conductive hearing loss of
variable degree.
 X-ray of mastoid will reveal clouding of air
cells with loss of cell outline.
HAHNEMANNIAN CLASSIFICATION OF
DISEASES:
Dynamic chronic
REPERTORY:
Boericke:
Inflammation (mastoiditis) -- Am. picr., Asaf.,
Aur., Bell., Benz. ac., Canth., Caps., Hep., Kali
m., Mag. p., Menthol, Onosm., Oniscus., Tellur.5
Kent:
EAR
PAIN, cramp in, evening
cutting in
mastoid process: Caust., con., mur-ac.6
The Essential SYNTHESIS:
EAR, Inflammation, Mastoid (= mastoiditis): Am-
pic, Ars, asaf, aur, aur-I, Bell, benz-ac, calc-p,
canth, caps, ferr-p, hep, kali-m, lach, mag-p,
mentho, Onos, pert, phos, pyrog, sil, streptoc, tell,
thuj, tub-a,
right side: mag-p
chronic: streptoc. 7
THERAPEUTICS:
Belladonna:
It is an effective medicine to reduce inflammation
of mastoid bone and relieve pain in ear.
Indications– ear pain that can be throbbing,
tearing, stitching or shooting type. The ear is also
hot and sensitive to touch, hardness of hearing.
They may also complain of noises in the ear.5
Kali Mur:
Reduce the chance of mastoiditis, discharge from
ear, hearing difficulty and snapping or popping
noises in ear.
Silicea:
It is considered when there is pus discharge from
ear either from infection in ear or mastoiditis. The
discharge has an offensive smell. Along with this
there is pain in mastoid bone behind the ear. Fever
may also be present. Persons needing it also
complain of boring or throbbing pain in ear.
Additionally they may have hissing or ringing
noises in ear and hearing loss. It is indicated for
cases where the mastoid bone is inflamed as well
as in cases where the decay of mastoid bone has
started.
Pulsatilla:
ear infection and mastoiditis. Its use is indicated
when there are yellow or yellowish green
discharges from ear. The discharge is profuse and
thick. With this there is pain and swelling behind
the ear. The pain is usually sharp or shooting in
nature. Sometimes pain in head appears along
with ear pain. Apart from above roaring or
humming noises in are may be present. High fever
may attend above symptoms.
Capsicum:
This medicine is very useful when area behind ear
is painful and it is highly sore and tender to touch.
This area is also swollen. Discharges from ear
appear with this. Burning and stinging sensation in
ear sometimes accompany this.
Merc Sol:
Ear pain at night time. The pain for using it can be
drawing, tearing or shooting in nature, presence of
thick yellow, green ear discharge having offensive
smell or pus discharge and sometimes blood
stained discharge from ear. Whistling or ringing
noise in ears is another prominent feature
appearing with this.
Hepar Sulph:
Pain in ear and there is sensitivity to touch ear.
Persons requiring it also have an offensive pus
discharge from ear in addition to above. They also
complain of roaring noises in ear and have
problems with hearing.
Tellurium: chronic cases of Mastoiditis
Constant pain in ear. The pain is mostly throbbing
type and continues day and night where it is
required. Another prominent symptom is thin,
watery, yellowish discharge from ear. The
discharge may be seen to continuously ooze from
ear. Sometimes with these symptoms hearing may
be impaired and noises of buzzing, ringing nature
in ear are present.
Ferrum Phos:
Soreness and swelling behind ear is marked.
Throbbing earache attends it. There are ringing
noises in ear and difficulty with hearing too with
above complaints. Discharge of mucus and pus
from ear also appears with these.
Aurum Met: INFECTION, 1Oth edition, 2014, Usha
for offensive ear discharge of pus. Along with Publications, Mumbai, 57,58
discharge, burning and prickling in ear arises. 3-Cassano, Pasquale & Ciprandi, Giorgio &
Difficulty in hearing attends to this. Lastly there Passali, Desiderio. (2020). Acute mastoiditis in
can be noises in ear of varying character like children. Acta bio-medica : Atenei Parmensis. 91.
buzzing, roaring, humming or rushing type. The 54-59. 10.23750/abm.v91i1-S.9259.
mastoid bone is inflamed or may also have even 4- Manche Santoshi Kumari, Jangla Madhavi,
started to decay in cases where it is indicated. Nagalla Bala Krishna, Koralla Raja Meghanadh,
Asafoetida: Akka Jyothy, Prevalence and associated risk
Asafoetida is beneficial when pain is in the side of factors of otitis media and its subtypes in South
head i.e. temporal region is marked with a Indian population, Egyptian Journal of Ear, Nose,
pushing out sensation. Boring type of pain is also Throat and Allied Sciences, Volume 17, Issue 2,
present behind the ear. Ear discharges having 2016, Pages 57-62,
offensive smell. The discharge is mostly thin and ISSN 2090-0740,
contains pus. Hardness of hearing is another https://doi.org/10.1016/j.ejenta.2016.04.001.
symptom that accompanies it. (https://www.sciencedirect.com/science/article/
Carbo Animalis: pii/S2090074016300019)
Carbo Animalis is used when a case present is 5-Boericke W, BOERICKE’S MANUAL OF
with sharp, stitching pain and swelling behind the HOMOEOPATHIC MATERIA MEDICA WITH
ear. buzzing noises in ear and discharge of pus REPERTORY: Ear.
from ear. 6-Kent repertory
Phosphorus: 7-Shroyens Fredrick, THE ESSENTIAL
This medicine is indicated when there is pain in SYNTHESIS, Ear.
ear and marked noises in ear. The pain for using it
may be throbbing, tearing or shooting type. The
shooting pain may also occur in head. When it
comes to noises in ear they can be ringing, roaring
or buzzing nature. Yellow coloured fluid
discharge from ear may be present too.
References:
1-Dhingra PL, Dhingra Shruthi, DISEASES OF
EAR, NOSE AND THROAT & HEAD AND NECK
SURGERY: Complications of otitis media, 7th
edition, Elsevier, Copyright © 2018 by RELX
India Pvt. Ltd.
2- K.B. Bhargava, S.K Bhatgava, T.M. Shah, A
SHORT BOOK OF E.N.T. DISEASES: MASTOID