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Acute mastoiditis typically presents following AOM or may be the first sign of AOM. Symptoms are present for ≪1 month.
Subdivided into two stages
Subacute mastoiditis (masked mastoiditis): indolent process, may occur with insufficiently treated AOM
Chronic mastoiditis: due to failed treatment of chronic otitis media. Usually associated with cholesteatoma; symptoms last months to years.
Children > adults
Most common in children ≪2 years of age
In children: males > females
Subclinical stage begins with AOM causing inflammation of mastoid air cells (likely present in all cases of AOM)
Obstruction of the aditus ad antrum (connecting the tympanic cavity and mastoid)
Increased pressure from fluid within the air cells leads to destruction of bony septae (acute mastoid osteitis/acute coalescent mastoiditis).
Acute mastoid osteitis can spread to adjacent areas in head and neck with abscess formation:
AOM: Haemophilus influenzae, S. pneumoniae
Acute mastoiditis: Streptococcus pneumoniae (most common), Streptococcus pyogenes, H. influenzae, Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA])
Chronic mastoiditis: Pseudomonas aeruginosa, S. aureus, Enterobacteriaceae, anaerobic bacteria, polymicrobials 3
Recurrent AOM or chronic suppurative otitis media
Pneumococcal conjugate vaccine
Early referral to ENT for chronic otitis media
Appropriate diagnosis and treatment of AOM
Prevention of recurrent AOM
Treat chronic eustachian tube dysfunction (pressure equalization tubes).
Identify cholesteatoma early.
Most common symptoms in infancy 2[A]
Pain/redness/swelling noted over mastoid.
At the time of admission 2[A]
Suspicion for mastoiditis increases when symptoms of AOM persist >2 weeks.
Postauricular changes: erythema, tenderness, edema, and/or fluctuance (81-85%) 2[A]
Bulging, erythematous, or dull tympanic membrane (60-71%)
Protrusion of auricle (79%)
Otorrhea if tympanic membrane is perforated
Edema of external auditory canal
Tympanic membrane (TM) can be normal in 10% of patients.
Postauricular cellulitis or inflammatory adenopathy
Severe otitis externa
Benign neoplasm: aneurysmal bone cyst, fibrous dysplasia
Malignant neoplasm: rhabdomyosarcoma, neuroblastoma
Deep neck space infections
CBC with differential: increased WBC count 4[C]
Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 3,4
Myringotomy/tympanocentesis: Send for cultures, Gram stain, acid-fast stain 2[B].
Mastoiditis is often a clinical diagnosis. CT confirms diagnosis and identifies regional complications.
If obvious physical exam and/or historical findings are absent, temporal bone imaging is recommended for patients with cervical or postauricular findings 5.
Plain radiographs of mastoid have low diagnostic yield but may show distortion of mastoid outline or clouding of mastoid air cells. These changes are not diagnostic and can also be seen in AOM.
CT findings (97% sensitivity; 94% positive predictive value) 6
CT of temporal bone with contrast helps identify suppurative extension 5[C].
Technetium-99m bone scan is more sensitive to osteolytic changes than CT.
Indications for CT scan in children 6[C]
MRI use increasing; may see increased fluid signal of mastoid air cells on T2-weighted MRI—an incidental finding in the absence of clinical signs
Tympanocentesis to obtain middle ear fluid for culture and sensitivity 2[B]
Myringotomy with culture (also therapeutic)
Audiography if suspected hearing loss
Obtain CSF if intracranial extension suspected.
Biopsy tissue protruding through TM or tympanostomy tube
IV antibiotics and myringotomy (± tympanostomy tubes) is the preferred treatment for uncomplicated acute mastoiditis (reflecting a shift away from more invasive surgical treatment).
Simple mastoidectomy is recommended for patients not responding to treatment after 3 to 5 days to avoid intracranial complications 7[C].
Inpatient care during acute phase for IV antibiotics
Keep the affected ear dry.
Empiric antibiotics against most common organisms: Streptococcus pneumoniae (including multiple resistant strains), Streptococcus pyogenes, Staphylococcus aureus (including MRSA), P. aeruginosa
Use combination therapy with 3rd generation cephalosporin (ceftriaxone or cefotaxime) plus clindamycin with additional coverage for resistant strains 5,7[C].
Ceftriaxone 1 to 2 g IV q24h
Clindamycin for coverage of ceftriaxone-resistant S. pneumoniae in pediatric patients 5[C]:
Cefotaxime 1 to 2 g IV q4-8h, depending on severity
Add vancomycin 30 to 60 mg/kg/day divided q8-12h if concerned for MRSA:
For patients with a history of recurrent AOM or recent antibiotic administration, treat with piperacillin-tazobactam 3.375 g IV q6h:
For other significant contraindications, precautions, or interactions, please refer to the manufacturer's literature.
Oral antibiotics are given after 7 to 10 days of IV antibiotics and once myringotomy/blood cultures identify pathogen and sensitivities. Common oral antibiotics include:
For chronic mastoiditis: Use topical drops, ofloxacin otic solution (0.3%) or neomycin, polymyxin B, hydrocortisone three drops, 3 to 4 times per day.
Perform tympanocentesis to obtain cultures and guide antibiotic choice 2[B].
Myringotomy and tympanostomy tubes allow drainage of middle ear 7[C].
Mastoidectomy is a definitive treatment for patients who fail to improve within 24 to 48 hours despite IV antibiotics and myringotomy and for those with meningeal or intracranial complications 6,7[C].
Simple mastoidectomy is most effective for management of subperiosteal abscesses, if a trial of conservative therapy with drainage, myringotomy, and IV antibiotics fails 8[C].
Clean ear canal under microscope to ensure pressure-equalization tube patency and adequate drainage of middle ear.
Topical antibiotic drops usually used after insertion of pressure-equalization tubes.
Admission criteria/initial stabilization
Avoid getting affected ear wet.
Oral antibiotics for 3 weeks following course of IV antibiotics (total duration of antibiotics is 4 weeks)
For chronic mastoiditis, consider several months of antimicrobial prophylaxis with amoxicillin.
Assess for hearing loss postoperatively (audiogram) after acute condition has subsided.
Follow-up with ENT, particularly patients with intracranial complications or hearing loss
Depends on severity and stage of disease
Conductive hearing loss may require reconstructive surgery.
Most cases of mastoiditis recover fully if the diagnosis is made early and treated appropriately.
Minks DP, Porte M, Jenkins N. Acute mastoiditis— the role of radiology. Clin Radiol. 2013;68(4): 397–405.
Pritchett CV, Thorne MC. Incidence of pediatric acute mastoiditis: 1997-2006. Arch Otolaryngol Head Neck Surg. 2012;138(5):451–455.
H70.90 Unspecified mastoiditis, unspecified ear
H70.009 Acute mastoiditis without complications, unspecified ear
H70.099 Acute mastoiditis with other complications, unspecified ear
H70.10 Chronic mastoiditis, unspecified ear
H70.013 Subperiosteal abscess of mastoid, bilateral
H70.011 Subperiosteal abscess of mastoid, right ear
H70.12 Chronic mastoiditis, left ear
H70.091 Acute mastoiditis with other complications, right ear
H70.13 Chronic mastoiditis, bilateral
H70.003 Acute mastoiditis without complications, bilateral
H70.092 Acute mastoiditis with other complications, left ear
H70.11 Chronic mastoiditis, right ear
H70.019 Subperiosteal abscess of mastoid, unspecified ear
H70.91 Unspecified mastoiditis, right ear
H70.002 Acute mastoiditis without complications, left ear
H70.92 Unspecified mastoiditis, left ear
H70.001 Acute mastoiditis without complications, right ear
H70.093 Acute mastoiditis with other complications, bilateral
H70.012 Subperiosteal abscess of mastoid, left ear
H70.93 Unspecified mastoiditis, bilateral
383.9 Unspecified mastoiditis
383.00 Acute mastoiditis without complications
383.02 Acute mastoiditis with other complications
383.1 Chronic mastoiditis
383.01 Subperiosteal abscess of mastoid
52404001 mastoiditis (disorder)
335846001 Acute mastoiditis without complications
111538005 Acute mastoiditis with complication
80645004 chronic mastoiditis (disorder)
109910003 Chronic suppurative mastoiditis
72102005 Subperiosteal abscess of mastoid
109909008 Acute suppurative mastoiditis
Suspect mastoiditis when symptoms of AOM persist >2 weeks despite a normal-appearing TM.
Hospitalize all patients with acute mastoiditis for IV antibiotics. Consult ENT for drainage procedure.
Treat with broad-spectrum IV antibiotics; collect middle ear fluid cultures to guide-specific therapy.
If conservative treatment fails after 3 to 5 days, perform mastoidectomy to avoid intracranial complications.