Ref Abses Mastoid

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216184/

Mastoid Abscess in Acute and Chronic Otitis Media

Mazita Ami, Zahirrudin Zakaria, [...], and Lokman Saim

Additional article information

Abstract

Background:

Mastoid abscess remains a recognised complication of otitis media despite the

advent of antibiotics. The objectives of this study were to describe the risk factors in

patients with mastoid abscess following acute and chronic otitis media and discuss

the management of this infection.

Method:

A retrospective analysis was done on all patients who underwent mastoidectomy for

mastoid abscess from January 2002 to December 2007. Data on the patients

presentation, associated complications, management, and follow-up were analysed.

Results:

A total of 12 patients were enrolled in this study population. Group A consisted of

patients with mastoid abscess preceded by acute otitis media, while Group Bconsisted of patients with mastoid abscess and chronic otitis media. In Group A (n=

7), 4 patients had a pre-morbid immunocompromised condition, but they did not

have cholesteatoma. None of the patients in Group B (n= 5) had any pre-morbid

illnesses. Out of 12 patients, 7 patients had associated extracranial complications,

and 1 patient had intracranial complications. Most patients recovered well after

mastoidectomy. Recurrence was noted in 1 patient who had acute lymphoblastic

leukaemia.
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Conclusion:

Mastoid abscess is still a recognised complication of acute otitis media, especially in

patients who are immunocompromised. Immunocompetent patients may also

develop mastoid abscess following chronic otitis media associated with

cholesteatoma. Thus, early treatment of otitis media and close vigilant follow-up are

advocated to ensure prompt detection of mastoid abscess complications.

Keywords: abscess, cholesteatoma, complications, immunocompromised patient,

mastoiditis, otitis media, otolyngology; head neck

Introduction

In the era of antibiotics, mastoid abscess is an uncommon complication of otitis

media. This has resulted in a decline in the incidence of mastoidectomy performed

for mastoid abscess. Nevertheless, there are still a number of patients who develop

mastoid abscess, which requires prompt diagnosis and management. Records of

patients who underwent mastoidectomy for mastoid abscess at Universiti

Kebangsaan Malaysia Medical Centre (UKMMC) were reviewed. The objective of this

review was to study the characteristics of patients who may have a higher risk ofdeveloping mastoid abscess following acute or chronic otitis media (COM).

Materials and Methods

This is a retrospective analysis of patients who underwent mastoidectomy for

mastoid abscess in UKMMC from 2002 to 2007. The operative census was reviewed

to identify patients who underwent mastoidectomy for mastoid abscess. The medical

records of these patients were reviewed to confirm the diagnosis of mastoid abscess

intra-operatively. The diagnosis of mastoid abscess was defined by findings of pus

within the coalescent mastoid air cells. This study was approved by the Research and

Ethics Committee of UKMMC (FF-242-2008).

Results

A total of 13 patients were identified in this study, and their ages ranged 370 years

old with a mean of 30.4 years old. Further data of 1 patient could not be traced and


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had to be omitted, which left a total of 12 cases. The patients were classified into 2

groups: Group A consisted of patients with mastoid abscess preceded by acute otitis

media (AOM), and Group B consisted of patients with mastoid abscess and

underlying COM. AOM was defined as having symptoms for duration of less than 12

weeks, and cases were classified as COM when symptoms persisted for 12 weeks or

longer. All patients in this series presented with unilateral ear infection.

Group A: Patients diagnosed with AOM with mastoid abscess

There were 7 patients categorised into Group A (Table 1). All paediatric patients (n=

3, age less than 12 years old) in this study were in this group. These patients had

aural symptoms between 3 and 28 days prior to presentation. Post-auricular swelling

was present in 3 patients, mastoid pain was present in 4 patients, and otorrhoea was

present in 2 patients. Otoscopic examination revealed perforated tympanic

membrane in 2 patients.

Table 1:

Demographics of patients diagnosed with acute otitis media with mastoid abscess (Group A)

There were 5 out of 7 patients who had other associated complications. There were

also 4 out of 7 patients in this group who had pre-morbid conditions leading to a

relatively immunocompromised state compared to the other subjects.

Cholesteatoma, however, was not noted in any of these patients.

Group B: Patients diagnosed with mastoid abscess and underlying COM

There were 5 patients categorised into Group B (Table 2). In this group, the patients

had chronic aural symptoms for 3 to 12 months and acute (new) symptoms for 2 to 6

weeks prior to presentation. Post-auricular swelling was present in 3 patients,

mastoid pain was present in 4 patients, and otorrhoea was present in 3 patients.
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Otoscopic examination revealed that all patients had a perforated tympanic

membrane. It was noted that only 3 out of the 5 patients had other associated

complications. All 3 patients had underlying cholesteatoma, but none of these

patients had any pre-morbid illnesses.

Table 2:

Demographics of patients diagnosed with acute otitis media with mastoid abscess (Group B)

Associated complications of otitis media

Out of 12 patients, 8 (66.7%) had complications of mastoiditis. These were mainly

extracranial complications, in 7 out of 8 patients: facial nerve palsy, in 3 patients,

Bezolds abscess, in 3 patients (Figure 1), and zygomatic root abscess in 1 patient

(Figure 2). In this series, only 1 patient had an associated intracranial complication of

meningitis.

Figure 1:

Coronal CT scan of a patient diagnosed with left mastoid abscess and Bezolds abscess (arrow)

Figure 2:

Axial CT scan of temporal bone showing right mastoid abscess and zygomatic root abscess

(arrows)
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Management and follow-up

All patients were admitted and started on broad-spectrum intravenous antibiotics.

Intravenous ceftriaxone was chosen because of its good blood-brain barrier

penetration. Ceftriaxone was administered at a dose of 1 g daily, unless patients had

intracranial complications, which required a dose of 2 g twice daily. The type of

antibiotics was modified according to the culture results. The duration of antibiotic

treatment was 2 weeks in all patients.

The bacteria isolated from patients pus culture were Staphylococcus aureus in 3

patients, Klebsiella pneumoniae in 2 patients, coagulase-negative Staphylococcus spp

in 1 patient and Pseudomonas aeruginosa in 1 patient. There were 2 patients withmixed growth, but the cultures contained predominantly Enterococcus spp. The

other 5 patients had no growth on operative specimen or swab culture.

All of the patients in this series had mastoid exploration for abscess drainage and

eradication of diseased mastoid air cells. Modified radical mastoidectomy was

performed in almost half of the patients (5 out of 12 patients). Cortical

mastoidectomy with myringotomy and ventilation tube insertion was performed in 4

patients, and 3 of those patients had AOM. Radical mastoidectomy was only

performed in 2 patients (1 from each group).

Post-operatively, all patients had a good recovery. The average follow-up period was

24 months (range 858 months), and 2 out of 12 patients were lost during the post-

operative follow-up. Only 1 patient with acute lymphoblastic leukaemia (ALL) in

Group A had a recurrence of mastoid abscess, which occurred 1 month later.

The patient with ALL developed AOM while undergoing chemotherapy; the patient

was treated with amoxicillin. Despite treatment compliance, the patient developed

lower motor neuron facial nerve palsy 5 days later. Radical mastoidectomy was

performed, which showed a bony dehiscent over the horizontal segment of the facial

nerve which was covered by granulation tissue. The stapes suprastructure was also

absent. Post-operatively, the facial nerve palsy improved from HouseBrackmann

grade IV to grade II. However, he had another episode of AOM with facial nerve

palsy grade V a month later. Unfortunately, due to pancytopenia and a poor general


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condition, he was deemed unfit for another mastoid exploration. This patient later

succumbed to the underlying haematological malignancy.

Discussion

The complications of otitis media are broadly categorised into extracranial and

intracranial complications. Extracranial complications (such as mastoiditis,

subperiosteal abscess, facial paralysis, and labyrinthitis) and intracranial

complications (such as cerebral or extradural abscess, meningitis, focal encephalitis,

lateral sinus thrombosis, and otic hydrocephalus) are more likely to be associated

with AOM than COM (13).

Since the introduction of antibiotics in the 1940s, the incidence of acute mastoiditis

and surgical intervention has declined. Recent publications, however, have noted an

increase in the incidence of acute mastoiditis following AOM in children (4,5).

Conversely, there has been a reduced incidence of COM since the 1990s. However,

the rate of extracranial and intracranial complications has remained stable (6). There

have been significant socioeconomic improvements in many countries during this

time. This is important because the established risk factors associated with COM

include low socioeconomic class, malnutrition, and congested living conditions (7).

Therefore, these studies seem to suggest an increased incidence of mastoiditis

following AOM compared with COM.

Mastoiditis has often been recognised as an extracranial complication of otitis media

when patients develop tender post-auricular swelling. The current treatment of

mastoiditis is mainly antibiotics with surgery reserved to myringotomy (5,8).

Mastoid abscess may develop as a complication of mastoiditis following both AOM

and COM (911). It occurs when purulent material collection accumulates within the

middle ear and mastoid air cells, and it is often accompanied by granulation tissue.

Surgical intervention is still the most common treatment for mastoid abscess.

Therefore, it is important to distinguish mastoid abscess from uncomplicated

mastoiditis and manage patients accordingly.

The most common clinical presentation of mastoid abscess in this series was a

tender, fluctuant post-auricular swelling, which was similar to other cases in the
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literature (11,12). Otorrhoea was less common, and facial asymmetry, neck swelling,

and meningism were even rarer. All of the patients with cholesteatoma had a history

of chronic otorrhoea since childhood.

Complications following COM were more prevalent in subjects with cholesteatoma

(13). Mustafa et al. showed that 15% of patients with COM had associated

cholesteatoma, and one-third of them presented with complications. In COM without

cholesteatoma, only 6.7% presented with complications. In the current series, the

numbers were too small to make any significant comparison; however, 3 out of 5

patients with mastoid abscess following COM had cholesteatoma. Interestingly, the

incidence of multiple complications can occur between 11% and 58% of cases and

appears to be more prevalent in patients with intracranial complications (1315).

Not surprisingly, the complication rate following COM has been reported to be

higher than that following AOM (14,15), but caution should be exercised in young

children with AOM because intracranial complications may occur relatively rapidly

in the course of the disease (16). In this series, there was only 1 patient with

meningitis as a complication of mastoid abscess. However, patients with mastoiditis

or mastoid abscess who did not undergo mastoid surgery was excluded; therefore,the series may not have captured these cases.

In our centre, patients with suspected mastoid abscess following mastoiditis were

promptly admitted and commenced on broad-spectrum intravenous antibiotics. A

high-resolution CT of the temporal bone and contrast-enhanced CT of the brain were

also performed in all patients. Mastoidectomy with abscess drainage was indicated

when there was purulent collection clinically, evidence on the CT scan or in patients

with cholesteatoma.

The predominant organisms cultured in this series were Staphylococcus aureus and

Klebsiella pneumoniae; however, there was no single predominant organism in AOM

or COM. There were 5 (42%) patients samples that exhibited no growth on routine

cultures. Previous antibiotic treatment may have resulted in the absence of bacterial

growth (4). In addition, tests for anaerobic cultures were not routinely performed in

our institution when anaerobes are expected to be prevalent in COM. Previousstudies have shown that common organisms in AOM include Streptococcus
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pneumoniae and Haemophilus spp. whereas common organisms in COM include

Proteus mirabilis, Enterococcus spp., and Pseudomonas aeruginosa (5,1315,17).

Mastoidectomy was performed expediently once the patients medical condition was

stabilised, and the decision to bring down the posterior canal wall or to perform

radical mastoidectomy was depended on the intra-operative findings. Generally,

intra-operative findings of intact ossicles with no cholesteatoma indicated cortical

mastoidectomy with myringotomy (if the tympanic membrane was intact). In this

series, intra-operative findings of ossicular erosion, including erosion of the stapes

suprastructure, led to radical mastoidectomy in two patients.

Interestingly, serious co-morbidities were noted to be present in patients who

developed mastoid abscess following AOM. The only 4 (25%) patients with pre-

morbid illness were those who developed mastoid abscess following AOM. These pre-

morbid conditions included ALL in 1 patient, BTM in 1 patient, and diabetes mellitus

in 2 patients. It is postulated that an immunocompromised state due to illness may

make a patient susceptible to developing mastoid abscess following AOM.

Factors that have been shown to influence the spread of infection include the type

and virulence of the infecting organism, host resistance, and the adequacy of

treatment (15). Patients with haematological malignancy, such as ALL, may present

with leukaemic infiltration of the temporal bone; however, this is uncommon.

Moreover, surgical findings often revealed greenish soft tissue mass with gelatinous

fluid within the middle ear (18), which was not evident in our patient. In this case, it

is postulated that enhanced organism virulence might explain the extensive ossicular

destruction despite the acute presentation. Interestingly, a study showed that

patients with BTM were prone to infection due to impaired phagocytic action and

anaemia (19). They are also prone to recurrent upper respiratory tract infections

because of generalised lymphoid hyperplasia and expanding marrow of facial bones,

which results in nasal obstruction. Patients with diabetes mellitus may present with

masked symptoms due to neuropathy. Both patients with diabetes mellitus

developed mastoid abscess with associated complications of meningitis or Bezolds

abscess in the absence of otorrhoea symptoms. The immunocompromised condition
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of these 4 patients could have resulted in the dissemination of infection before any

apparent ear symptoms.

Therefore, early adequate treatment of AOM and close vigilant follow-up are

important, especially in immunocompromised patients. Antibiotic treatment,

however, does not provide absolute protection against the development of

complications and, at worst, may mask the symptoms and signs of complications

(4,16). Increasing antibiotic resistance behaviours by organisms in biofilms

(demonstrated in Streptococcus pneumonia and Haemophilus influenza) may

explain why antibiotic treatment does not provide absolute protection (17).

Facial nerve palsy occurred in 4 out of 12 patients in this series; 3 were patients with

AOM had facial nerve palsy grade IV to VI (HouseBrackmann), which improved

after surgery (to grade II at best). The other patient had COM and grade II facial

palsy, which had improved to grade I on the second post-operative day. These

observations were in contrast to previous studies, which reported total recovery in all

AOM patients with facial paralysis (20,21). They were also in contrast to another

study, which suggested that facial paralysis in COM had a poor prognosis (22).

A literature review by White and McCans (23)suggested that several potential

processes were involved in facial palsy secondary to otitis media: 1) direct

involvement of the facial nerve by bacterial invasion, 2) mechanical compression on

the vascular supply of the nerve by the purulent exudates or granulation tissue, 3)

acute toxic neuritis with venous thrombosis resulting in ischaemia, and 4) bacterial

toxins that lead to facial nerve demyelination. More than one of these processes may

be involved in the pathophysiology of facial palsy.

Therefore, it is postulated that the recovery of facial nerve function may depend on

the underlying pathophysiological processes that resulted in the facial nerve palsy.

Recent studies using the results of electrophysiological tests have shown that facial

nerve palsy secondary to AOM may be treated clinically (24,25). Another study on

facial nerve palsy due to non-cholesteatomatous otitis media also showed good

recovery without surgical decompression of the nerve (25,26). However, facial nerve

palsy associated with cholesteatoma tends to have a poor prognosis, and mastoidsurgery is required to create a safe and dry ear.
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Conclusion

Despite the advancements in the treatment of otitis media, mastoid abscess is still a

recognised complication in both acute and COM. Although mastoid abscess can

occur over a wide age spectrum (370 years old), it predominantly occurs in adults.

Patients who are immunocompromised have a greater risk of developing mastoid

abscesses secondary to AOM. They may also present with vague symptoms, severe

disease or other associated complications that require vigilance on the part of the

physician. Mastoid abscesses may also develop in immunocompetent patients with

COM, especially in association with cholesteatoma. In contrast to previously

published data, facial palsy secondary to AOM may not recover completely.

Footnotes

Authors Contributions

Conception and design: MA

Provision of study materials or patients: GBS, AA

Collection and assembly of data: ZZ

Analysis and interpretation of the data: ZZ

Drafting of the article: MA, ZZ

Critical revision of the article: MA, GBS, AA

Final approval of the article: LS

Article informationMalays J Med Sci. 2010 Oct-Dec; 17(4): 4450.

PMCID: PMC3216184

Mazita Ami,1Zahirrudin Zakaria,2Bee See Goh,1Asma Abdullah,1andLokman Saim1

1Department of OtorhinolaryngologyHead and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan

Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia

2Department of Otorhinolaryngology, Hospital Pulau Pinang, 10990 Pulau Pinang, Malaysia

Correspondence: Dr Mazita Ami, MS (ORLHNS), Department of OtorhinolaryngologyHead and Neck

Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak,

56000 Kuala Lumpur, Malaysia, Fax: +603- 91737840, E-mail: mazitaami/at/yahoo.com
http://www.ncbi.nlm.nih.gov/pubmed/?term=Ami%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ami%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Zakaria%20Z%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Zakaria%20Z%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Zakaria%20Z%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Goh%20BS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Goh%20BS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Goh%20BS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Abdullah%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Abdullah%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Abdullah%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Saim%20L%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Saim%20L%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Saim%20L%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Saim%20L%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Abdullah%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Goh%20BS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Zakaria%20Z%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ami%20M%5Bauth%5D


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Received November 1, 2009; Accepted March 18, 2010.

Copyright Penerbit Universiti Sains Malaysia, 2010

Articles from The Malaysian Journal of Medical Sciences : MJMS are provided here courtesy of School of

Medical Sciences, Universiti Sains Malaysia

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http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm

Mastoiditis

The mastoid process is an inferior extension of the petrous temporal bone of the skull and

provides a structural function as an anchor point for the large muscles of the neck. It contains

multiple air cells that develop from a single main cavity (the antrum), after the age of about two.

In cross-section, it has a vacuolated or honeycomb appearance.

The tympanic cavity of the middle ear is in communication with the mastoid antrum via a small

canal that runs through the petrous temporal bone. The mastoid air cells are related superiorly to

the middle cranial fossa, and posteriorly to the posterior cranial fossa. This means that

suppuration in the mastoid may, rarely, spread to cause meningitis or a cerebral abscess. Other

surrounding structures include the facial nerve canal, the sigmoid sinus and the lateral sinus.

Mastoiditis occurs when suppurative infection extends from a middle ear affected byotitis mediato

the mastoid air cells. The infective process causes inflammation of the mastoid and surrounding

tissues and may lead to bony destruction.

Classification[1] Classic, or acute, mastoiditis is a rare complication of acute otitis media (AOM). Chronic, latent, or masked, mastoiditis presents in a chronic, or subclinical, fashion. It is usually

associated withchronic suppurative otitis mediaorcholesteatoma.

Epidemiology

Mastoiditis in acute or chronic form is now quite rare.

Before the advent of antibiotics, mastoiditis was relatively common. It developed in 5-10% of

children with acute otitis media (AOM), with a mortality rate of 2 per 100,000 children. The

mortality rate is now


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The patient may complain of deafness and there may be signs ofconductive deafness(Rinne's test

negative;Weber's test- sound localised/loudest in the affected ear).

There may be no history of otitis media, no mastoid area tenderness and no external signs of

infection.[1]

Differential diagnosis Otitis media or externa.

Trauma to the ear/mastoid.

Cervical lymph node enlargement.

Meningitis.

Cellulitis.

Parotid swelling.

Bone cysts or tumours.

Basal skull fracture.

Other source of intracranial or localised sepsis. Pyrexia of unknown origin.

Investigations

FBC may show leukocytosis.

ESR may be elevated.

Blood cultures should be taken.

Fluid can be extracted from the middle ear through perforated drums or by intervention

(tympanocentesis) and should be sent for Gram staining, culture and acid-fast stain.[1]

Skull X-ray of the mastoid area is not usually helpful but may show clouding of mastoid air cells.

CT and/or MRI scanning can be used for to aid diagnosis and look for intracranial complications.Some say that CT scanning should be used in all suspected cases of mastoiditis and others suggest a

more conservative approach.[1][10]In addition, MRI may be less useful than CT scanning.[11]

Lumbar puncture should be carried out if intracranial spread is suspected.

Audiograms during and after mastoiditis help to quantify and monitor any associatedhearing loss.

Management

Patients with suspected mastoiditis should be managed in a hospital setting.

Appropriate clinical suspicion and prompt diagnosis are important to reduce the likelihood of

complications.

The usual initial therapy is high-dose, broad-spectrum intravenous (IV) antibiotics, given for at least

1-2 days (eg with a third-generationcephalosporin).[1]

Oral antibiotics are usually used after this, starting on IV treatment after 48 hours without fever, and

continuing for at least 1-2 weeks.

Paracetamol, ibuprofen and other agents may be given as antipyretics and/or painkillers.

Myringotomy tympanostomy tube insertion may be performed in some cases as a therapeutic

procedure, or to collect middle ear fluid for culture.
http://www.patient.co.uk/search.asp?searchterm=CONDUCTIVE+DEAFNESS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONDUCTIVE+DEAFNESS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONDUCTIVE+DEAFNESS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=WEBER+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=WEBER+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=WEBER+TEST&collections=PPsearchhttp://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/search.asp?searchterm=PAROTID+SWELLING&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PAROTID+SWELLING&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PYREXIA+OF+UNKNOWN+ORIGIN&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PYREXIA+OF+UNKNOWN+ORIGIN&collections=PPsearchhttp://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-10http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-10http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-10http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-11http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-11http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-11http://www.patient.co.uk/search.asp?searchterm=HEARING+IMPAIRMENT&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HEARING+IMPAIRMENT&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HEARING+IMPAIRMENT&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CEPHALOSPORIN&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CEPHALOSPORIN&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CEPHALOSPORIN&collections=PPsearchhttp://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/search.asp?searchterm=CEPHALOSPORIN&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HEARING+IMPAIRMENT&collections=PPsearchhttp://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-11http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-10http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/search.asp?searchterm=PYREXIA+OF+UNKNOWN+ORIGIN&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PAROTID+SWELLING&collections=PPsearchhttp://www.patient.co.uk/doctor/Mastoid-and-Mastoiditis.htm#ref-1http://www.patient.co.uk/search.asp?searchterm=WEBER+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONDUCTIVE+DEAFNESS&collections=PPsearch


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Surgical intervention, usually in the form of mastoidectomy tympanoplasty, is suggested if there

is:[1]

Mastoid osteitis.

Intracranial extension.

Abscess formation. Co-existing cholesteatoma.

Limited improvement after IV antibiotics.

Mastoidectomy can be:[1]

Simple: infected mastoid air cells are removed.

Radical: the tympanic membrane and most middle ear structures are removed and the

Eustachian tube is closed.

Modified: the ossicles and part of the tympanic membrane is preserved.

Incision and drainage of a subperiosteal abscess in another procedure that may be required.

Patients with intracranial spread may also need neurosurgical intervention.

In cases with unusual infecting organisms, specialist infectious disease input may be helpful.

Complications

Conductive and/orsensorineural hearing loss.

Osteomyelitisor bone erosion.

Extension to the zygoma (zygomatic mastoiditis).

Subperiosteal abscess (abscess between the periosteum and mastoid bone; gives appearance of a

protruding ear).

Cranial nerve palsies (especially V, VI and VII).

Intracranial spread leading toextradural abscess,cerebral abscess,subdural empyemaand

meningitis.

Intracranialvenous sinus thrombosis(eg lateral sinus thrombosis).

Bezold's abscess (spread of pus from mastoid process along the digastric muscle to other neck

muscles).[12]

Petrositiscausing Gradenigo's syndrome (VIth cranial nerve palsy + deep trigeminalfacial pain+

suppurative otitis media).

Carotid artery spasm, arteritis, occlusion, rupture or metastatic septic emboli leading to intracerebral

infection (all very rare and associated with the most severe cases).

Prognosis

Nowadays the prognosis for the vast majority of cases that are diagnosed early is excellent with a low

chance of complications or severe hearing loss. A recent review reported that most who had suffered an

episode of acute mastoiditis had no long-term otological sequelae.[13]However, complicated cases may

still lead to significant morbidity or even death.

Prevention

The disease itself is difficult to prevent, except possibly by electing to treat some severe cases of acute

otitis media (AOM) with adequate doses and duration of appropriate antibiotics. The sequelae of the

condition can be prevented by having an appropriate index of suspicion for the condition and admitting

patients suspected of having mastoiditis for early hospital assessment.
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Medicolegal considerations

Failure to diagnose mastoiditis leading to life-threatening complications or death, is a recurrent, if

relatively rare, cause of legal claims made against general practitioners in the UK. It should be borne in

mind that the symptoms and signs can be quite subtle in chronic or latent mastoiditis.

Provide Feedback

Further reading & references

Kavanagh K;Acute Coalescent Mastoiditis, Otology online, ENT USA.; good images including the

protruding auricle

1. Chase KS et al;Mastoiditis, Medscape, Sep 2009

2. Bluestone CD;Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J.

2000 May;19(5 Suppl):S37-46.

3. Brook I;Antimicrobial therapy of otitis media reduces the incidence of mastoiditis. Curr Infect Dis

Rep. 2010 Jan;12(1):1-3.

4. Otitis media - acute,Clinical Knowledge Summaries (July 2009)

5. Damoiseaux RA;Antibiotic treatment for acute otitis media: time to think again. CMAJ. 2005 Mar

1;172(5):657-8.

6. Sharland M, Kendall H, Yeates D, et al;Antibiotic prescribing in general practice and hospital

admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis.

BMJ. 2005 Aug 6;331(7512):328-9. Epub 2005 Jun 20.

7. Glasziou PP et al.,;Antibiotics for acute otitis media in children. Cochrane review abstract and plain

language summary. Cochrane Database of Sytematic Reviews. 2006(2).8. Diagnosis and management of childhood otitis media in primary care,Scottish Intercollegiate

Guidelines Network - SIGN (2003)

9. Petersen I, Johnson AM, Islam A, et al;Protective effect of antibiotics against serious complications

of common respiratory tract infections: retrospective cohort study with the UK General Practice

Research Database. BMJ. 2007 Nov 10;335(7627):982. Epub 2007 Oct 18.

10. Tamir S, Schwartz Y, Peleg U, et al;Acute mastoiditis in children: is computed tomography always

necessary? Ann Otol Rhinol Laryngol. 2009 Aug;118(8):565-9.

11. Polat S, Aksoy E, Serin GM, et al;Incidental diagnosis of mastoiditis on MRI. Eur Arch

Otorhinolaryngol. 2011 Feb 5.

12. Jose J, Coatesworth AP, Anthony R, et al;Life threatening complications after partially treated

mastoiditis. BMJ. 2003 Jul 5;327(7405):41-2.

13. Glynn F, Osman L, Colreavy M, et al;Acute mastoiditis in children: presentation and long term

consequences. J Laryngol Otol. 2008 Mar;122(3):233-7. Epub 2007 Jul 19.

Disclaimer:This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS

has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health

care professional for diagnosis and treatment of medical conditions. For details see ourconditions.

Original Author: Dr Sean Kavanagh, Dr Michelle Wright Current Version:Dr Gurvinder Rull

Last Checked: 23/05/2011 Document ID: 947 Version: 25 EMIS
http://www.patient.co.uk/feedback.asp?ref=%2fdoctor%2fMastoid-and-Mastoiditis.htmhttp://www.patient.co.uk/feedback.asp?ref=%2fdoctor%2fMastoid-and-Mastoiditis.htmhttp://www.entusa.com/acute_coalescent_mastoiditis.htmhttp://www.entusa.com/acute_coalescent_mastoiditis.htmhttp://www.emedicine.com/emerg/TOPIC306.HTMhttp://www.emedicine.com/emerg/TOPIC306.HTMhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10821471http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10821471http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21308493http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21308493http://www.cks.nhs.uk/otitis_media_acutehttp://www.cks.nhs.uk/otitis_media_acutehttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15738492http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15738492http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15967760http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15967760http://www.cochrane.org/reviews/en/ab000219.htmlhttp://www.cochrane.org/reviews/en/ab000219.htmlhttp://www.sign.ac.uk/guidelines/fulltext/66/index.htmlhttp://www.sign.ac.uk/guidelines/fulltext/66/index.htmlhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17947744http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17947744http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19746754http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19746754http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21298388http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21298388http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12842957http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12842957http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17640433http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17640433http://www.patient.co.uk/disclaimer.asphttp://www.patient.co.uk/disclaimer.asphttp://www.patient.co.uk/disclaimer.asphttp://www.patient.co.uk/authors/dr-gurvinder-rullhttp://www.patient.co.uk/authors/dr-gurvinder-rullhttp://www.patient.co.uk/authors/dr-gurvinder-rullhttp://www.patient.co.uk/authors/dr-gurvinder-rullhttp://www.patient.co.uk/disclaimer.asphttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17640433http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12842957http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21298388http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19746754http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17947744http://www.sign.ac.uk/guidelines/fulltext/66/index.htmlhttp://www.cochrane.org/reviews/en/ab000219.htmlhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15967760http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15738492http://www.cks.nhs.uk/otitis_media_acutehttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=21308493http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10821471http://www.emedicine.com/emerg/TOPIC306.HTMhttp://www.entusa.com/acute_coalescent_mastoiditis.htmhttp://www.patient.co.uk/feedback.asp?ref=%2fdoctor%2fMastoid-and-Mastoiditis.htm


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http://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatments

Mastoiditis

Mastoiditis is a bacterial infection of the mastoid bone. The mastoid bone, which sits behind theear,consists of air spaces that help drain the middle ear.

When the mastoid cells become infected or inflamed, often as a result of an unresolved middleear

infection(otitis media), mastoiditis can develop. In acute mastoiditis, infection may spread outside of

the mastoid bone and cause serious health complications.

Recommend ed Related to Ear Infect ion

Understanding Ear Infection -- Prevention

Because bottle-fed babies are more likely to get ear infections, it is better to breast feed your infant for the first six to12 months of life, if possible, to prevent ear infections. Remove as many environmental pollutants from your homeas you can, including: Dust Cleaning fluid and solvents Tobacco smoke Also, reduce yours or your child's exposureto people with colds, and control allergies.

Read the Understanding Ear Infection -- Prevention article > >

Mastoiditis typically affects children, but adults can also be affected.

Some people have chronic mastoiditis, an ongoing infection of the middle ear and mastoid causing

persistent drainage from the ear.

Mastoiditis Causes

As mentioned above, mastoiditis often develops as a result of a middle ear infection. Bacteria from

the middle ear can travel into the air cells of the mastoid bone. In addition, a

skincyst(cholesteatoma) in the middle ear may block drainage of the ear, leading to mastoiditis.

Mastoiditis Symptoms

Mastoiditis symptoms may include:

Fever,irritability, and lethargy

Swelling of the ear lobe

Redness and tenderness behind the ear

Drainage from the ear

Bulging and drooping of the ear (in acute mastoiditis)

Mastoiditis Diagnosis

Any unusual ear or fever symptoms should be evaluated by a doctor. The doctor will look inside theear with a special instrument to see if an infection is present and evaluate ear function. If mastoiditis is

suspected, your doctor may recommend other tests to confirm the diagnosis, including:

bloodtests

X-ray

ear culture (removal of fluid or other substances from the ear to check for infection)

If severe infection is suspected, your doctor may also recommend more in depth tests, such as aCT

scanorMRI.If your doctor is concerned you may have developedmeningitisas a result of

mastoiditis, a lumbar puncture will be performed to test spinal fluid for infection.

Mastoiditis Treatments
http://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatmentshttp://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatmentshttp://www.webmd.com/brain/picture-of-the-earhttp://www.webmd.com/brain/picture-of-the-earhttp://www.webmd.com/brain/picture-of-the-earhttp://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-basicshttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-basicshttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-basicshttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/skin-problems-and-treatments/cystshttp://www.webmd.com/skin-problems-and-treatments/cystshttp://www.webmd.com/skin-problems-and-treatments/cystshttp://children.webmd.com/tc/fever-age-4-and-older-topic-overviewhttp://children.webmd.com/tc/fever-age-4-and-older-topic-overviewhttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mrihttp://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mrihttp://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mrihttp://children.webmd.com/vaccines/tc/meningitis-topic-overviewhttp://children.webmd.com/vaccines/tc/meningitis-topic-overviewhttp://children.webmd.com/vaccines/tc/meningitis-topic-overviewhttp://children.webmd.com/vaccines/tc/meningitis-topic-overviewhttp://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mrihttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-bodyhttp://www.webmd.com/heart/anatomy-picture-of-bloodhttp://children.webmd.com/tc/fever-age-4-and-older-topic-overviewhttp://www.webmd.com/skin-problems-and-treatments/cystshttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-preventionhttp://www.webmd.com/cold-and-flu/ear-infection/understanding-otitis-media-basicshttp://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/cold-and-flu/ear-infection/http://www.webmd.com/brain/picture-of-the-earhttp://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatments


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Chronic mastoiditis is treated with oral antibiotics, eardrops, and regular ear cleanings by a doctor. If

these treatments do not work, surgery may be necessary to prevent further complications.

If you or your child is diagnosed with acute mastoiditis, you may be put in the hospital to receive

treatment and care by an otolaryngologist, a doctor who specializes in ear, nose, and throat disorders.

Antibiotics will be given through an IV (intravenous line) to treat the infection.

Surgery may also be needed to drain the fluid from the middle ear, called a myringotomy. During a

myringotomy, the doctor makes a small hole in the eardrum to drain the fluid and relieve pressure

from the middle ear. A small tube may be inserted into the middle ear to ventilate and prevent fluid

from getting into the middle ear. Typically, the tube will fall out on its own after six to 12 months.

If the infection is severe, a mastoidectomy surgical procedure may be needed to remove the infected

bone behind the ear.

If left untreated, mastoiditis can cause serious, even life-threatening, health complications,

includinghearing loss,blood clot, meningitis, or abrainabscess. But with early and appropriate

antibiotic treatment, these complications can be avoided and you can recover completely.

If you are prone to middle ear infections, don't let them go untreated. All bacterial ear infections

should receive timely treatment with an appropriate antibiotic to prevent mastoiditis, and other serioushealth complications.

Further Reading:

Slideshow: Anatomy of an Ear Infection

What are the symptoms of acute otitis media (middle ear infection)?

All About Ear Infections

Symptoms of an Ear Infection

Ear Infections-Related Information

Ear Infections-When To Call a Doctor

Ear Problems and Injuries, Age 11 and Younger-Preparing For Your Appointment

See All Baby Ear Infections Topics

Top Picks

Photos: Anatomy of an Ear Infection

Photos: Natural Cold Remedies That Work

Photos: Assess Your Sore Throat

Earache: Cold or Ear Infection?

What Is an Ear Infection?

How to Treat an Ear Infection

WebMD Medical Reference

View Article Sources

Reviewed byKimball Johnson, MDon September 01, 2012

2012 WebMD, LLC. All rights reserved.
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