Thissiteisintendedforhealthcareprofessionals

MastoiditisClinicalPresentation
PRESENTATION

History
Mostpatients(>80%)havenohistoryofrecurrentotitismedia.Persistentotorrheabeyond3weeks
isthemostconsistentsignthataprocessinvolvingthemastoidhasevolved.
Thepatientsfevermaybehighandunrelentinginacutemastoiditis,butthismayberelatedtothe
associatedacuteotitismedia(AOM).Persistenceoffever,particularlywhenthepatientisreceiving
adequateandappropriateantimicrobialagents,iscommoninacutesurgicalmastoiditis(ASM).
Painislocalizeddeepinorbehindtheearandistypicallyworseatnight.Persistenceofpainisa
warningsignofmastoiddisease.Thismaybedifficulttoevaluateinveryyoungpatients.Hearing
lossiscommonwithallprocessesthatinvolvethemiddleearcleft.
Forinfants,beattentivetoanynonspecifichistoryconsistentwithinfection,suchaspoorfeeding,
fever,irritability,ordiarrhea.
InastudybyOestreicherKedemetal,themeanintervalfromonsetofillnesstomastoiditiswas
foundtobe4.5days.[9]EarculturesmostoftengrewSpneumoniaeandPaeruginosa(23.7%
each).Complicationsoccurredin15.8%ofcases.Theonlyfactordifferentiatingchildrenwithand
withoutcomplicationswasthewhitebloodcellcount(highinchildrenwithcomplications).
Thefindingsinthisstudyindicatethatacutemastoiditisisnotonlyacomplicationofprolonged
infectionofthemiddleearbutalsomaypresentasanacuteinfectionofthemastoidbonethatcan
progresswithin48hours.Thecomplicationrateremainshigh,andantibiotictreatmentattheonset
ofsymptomsdoesnotpreventcomplications.Ahighwhitebloodcellcountonadmissionmay
serveasapredictivefactorforcomplicatedcases.
InastudybyNivetalof113patientswithacutemastoiditis(128episodes)treatedbetween1990
and2002,theauthorsconcludedthat(1)asignificantincreaseintheincidenceofacutemastoiditis
ininfantshadbeenrecorded,althoughthereasonforthetrendwasuncertain(2)inmostinfants
withacutemastoiditis,thediseasearoseaftertheinfant'sinitialAOMepisode,andmostofthe
infantshadnotreceivedpriorantibiotictherapy(3)infantsshowedmoresevereclinicalsignsand
symptomsofacutemastoiditisthandidolderpatients(4)Spneumoniawasthemostcommon
pathogenisolatedinmiddleearfluidcultures,buttherewasagreaterinvolvementofSpyogenes
inthecasesofacutemastoiditisthanhadbeenreportedforAOM.[10]

PhysicalExamination
Acutemastoiditisisaseriousbacterialinfectionofthetemporalboneandisthemostcommon
complicationofotitismedia.Frequentsymptomsincludemastoidareaerythema,proptosisofthe
auricle,andfever.[11]
Tendernessandinflammationoverthemastoidprocessisthemostconsistentsignofacute
surgicalmastoiditis(ASM).Periostealthickeningrequirescomparisontotheotherside,andsome
lateraldisplacementoftheauriclemaybepresent.Subperiostealabscessdisplacestheauricle
laterallyandobliteratesthepostauricularskincrease.Ifthecreaseremains,theprocessislateral
totheperiosteum.

Althoughthediagnosisofacutesurgicalmastoiditiscanoftenbemadeonaclinicalbasisalone,
computedtomography(CT)scanningmaybeperformedforconfirmationofthediagnosis,
evaluationofpotentialcomplications,andsurgicalplanning.Alsokeepinmindthatitispossibleto
havemastoiditiswithnohistoryofotitismedia,normalexternalanatomy,notenderness,andno
externalsignsofinfection.
Otitismediaisrevealedonotoscopy,oftenwith1ofthefollowingadditionalfeatures:
Saggingoftheposterosuperiorcanalwall(possiblyasignofASM,althoughnotasreliablein
infants)
Nipplelikeprotrusionofthecentraltympanicmembrane,usuallyoozingpus
Findingsconsistentwithacomplicationofextensionbeyondthemastoidprocessandits
coveringperiosteumoranotherintratemporalcomplication,suchasfacialpalsy
Inadults,themostcommonsymptomsofmastoiditisareotalgia,otorrhea,andhearingloss,and
thephysicalsignsofmastoiditis(ie,swelling,erythema,tendernessoftheretroauricularregion)are
usuallypresent.Localizationandenlargementofthepathologicalprocesswithinthemiddleear
spacescanbedeterminedbasedonCTscanfindings.
DifferentialDiagnoses
References

1.CasulaS,CastroJG,EspinozaLA.Anunusualcauseofmastoiditisthatevolvedintomultiple
ringenhancingintracerebrallesionsinapersonwithHIVinfection.AIDSRead.2007Aug.
17(8):4024.[Medline].
2.OngkasuwanJ,ValdezTA,HultenKG,MasonEOJr,KaplanSL.Pneumococcalmastoiditis
inchildrenandtheemergenceofmultidrugresistantserotype19Aisolates.Pediatrics.2008
Jul.122(1):349.[Medline].
3.NussinovitchM,YoeliR,ElishkevitzK,VarsanoI.Acutemastoiditisinchildren:
epidemiologic,clinical,microbiologic,andtherapeuticaspectsoverpastyears.ClinPediatr
(Phila).2004Apr.43(3):2617.[Medline].
4.PsarommatisIM,VoudourisC,DourosK,GiannakopoulosP,BairamisT,CarabinosC.
Algorithmicmanagementofpediatricacutemastoiditis.IntJPediatrOtorhinolaryngol.2012
Jun.76(6):7916.[Medline].
5.PalmaS,BovoR,BenattiA,AimoniC,RosignoliM,LibanoreM,etal.Mastoiditisinadults:a
19yearretrospectivestudy.EurArchOtorhinolaryngol.2013Apr16.[Medline].
6.HalgrimsonWR,ChanKH,AbzugMJ,etal.IncidenceofacutemastoiditisinColorado
childreninthepneumococcalconjugatevaccineera.PediatrInfectDisJ.2014May.
33(5):4537.[Medline].
7.MaromT,TanA,WilkinsonGS,etal.Trendsinotitismediarelatedhealthcareuseinthe
UnitedStates,20012011.JAMAPediatr.2014Jan.168(1):6875.[Medline].[FullText].
8.LuntzM,BrodskyA,NusemS,KronenbergJ,KerenG,MigirovL,etal.Acutemastoiditis
theantibioticera:amulticenterstudy.IntJPediatrOtorhinolaryngol.2001Jan.57(1):19.
[Medline].
9.OestreicherKedemY,RavehE,KornreichL,PopovtzerA,BullerN,NagerisB.
Complicationsofmastoiditisinchildrenattheonsetofanewmillennium.AnnOtolRhinol
Laryngol.2005Feb.114(2):14752.[Medline].
10.NivA,NashM,SlovikY,FlissDM,KaplanD,LeibovitzE,etal.Acutemastoiditisininfancy:
theSorokaexperience:19902000.IntJPediatrOtorhinolaryngol.2004Nov.68(11):14359.

[Medline].
11.vandenAardwegMT,RoversMM,deRuJA,AlbersFW,SchilderAG.Asystematicreviewof
diagnosticcriteriaforacutemastoiditisinchildren.OtolNeurotol.2008Sep.29(6):7517.
[Medline].
12.VazquezE,CastelloteA,PiquerasJ,MauleonS,CreixellS,PumarolaF,etal.Imagingof
complicationsofacutemastoiditisinchildren.Radiographics.2003MarApr.23(2):35972.
[Medline].
13.NationalCancerInstitute.RadiationRisksandPediatricComputedTomography(CT):A
GuideforHealthCareProviders.NationalInstitutesofHealth.Availableat
http://www.cancer.gov/cancertopics/causes/radiation/radiationriskspediatricCT.Accessed:
October2,2011.
14.SaatR,LaulajainenHongistoAH,MahmoodG,etal.MRimagingfeaturesofacute
mastoiditisandtheirclinicalrelevance.AJNRAmJNeuroradiol.2015Feb.36(2):3617.
[Medline].
15.EnokssonF,GrothA,HultcrantzM,StalforsJ,StenfeldtK,HermanssonA.Subperiosteal
abscessesinacutemastoiditisin115Swedishchildren.IntJPediatrOtorhinolaryngol.2015
Jul.79(7):111520.[Medline].
16.RoddyMG,GlazierSS,AgrawalD.Pediatricmastoiditisinthepneumococcalconjugate
vaccineera:symptomdurationguidesempiricantimicrobialtherapy.PediatrEmergCare.
2007Nov.23(11):77984.[Medline].
17.MinoviA,DazertS.Diseasesofthemiddleearinchildhood.GMSCurrTopOtorhinolaryngol
HeadNeckSurg.2014.13:Doc11.[Medline].[FullText].
18.SinghS,RettigantiMR,QinC,KuruvaM,HegdeSV.Incidentalmastoidopacificationin
childrenonMRI.PediatrRadiol.2016May.46(5):7048.[Medline].
19.AdamsDJ,SusiA,ErdieLalenaCR,etal.OtitisMediaandRelatedComplicationsAmong
ChildrenwithAutismSpectrumDisorders.JAutismDevDisord.2016May.46(5):163642.
[Medline].
MediaGallery

Mastoiditiswithsubperiostealabscess.Notethelossoftheskincreaseandthepointed
abscess.

Corticalmastoidectomyinadenselysclerosedmastoid.

Preoperativepreparationofthepatient.

Drapingthesurgicalarea.

Injectionoftheareawith2%Xylocaineand1:100,000adrenalinetoreducebleeding.

Markingtheincisionsite.

Placementoftheincision,afewmmbehindthepostauricularsulcus.

Deepeningtheincisiondowntothebone.

Elevationoftheperiosteumtoexposethemastoidcortextothemastoidtip.

Mastoiddrillinginprogresswithsimultaneoussalineirrigation.

Creationoftheinitialgrooveandtheverticalline.

Exposureoftheantrumandexenterationofthemastoidaircells.

Curettingtheaditustoenlargeit.

Furtherexposure.

Healedpostauralscar.

Extentofcorticalmastoidectomyinawellpneumatizedmastoid.
of16

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ContributorInformationandDisclosures

Author
PPDevan,MBBS,MSProfessorandHead,DeptofENT,AJInstituteofMedicalSciences,
Mangalore,India
Disclosure:Nothingtodisclose.
Coauthor(s)
JohnDDonaldson,MD,FRCSC,FACSPediatricOtolaryngologist,ChiefofSurgery,Galisano
Children'sHospital,LeeMemorialHealthSystem
JohnDDonaldson,MD,FRCSC,FACSisamemberofthefollowingmedicalsocieties:American
AcademyofOtolaryngologyHeadandNeckSurgery,AmericanSocietyofPediatric
Otolaryngology,AmericanAcademyofPediatrics,AmericanCollegeofSurgeons

Disclosure:Nothingtodisclose.
ChiefEditor
ArlenDMeyers,MD,MBAProfessorofOtolaryngology,Dentistry,andEngineering,Universityof
ColoradoSchoolofMedicine
ArlenDMeyers,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyof
FacialPlasticandReconstructiveSurgery,AmericanAcademyofOtolaryngologyHeadandNeck
Surgery,AmericanHeadandNeckSociety
Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:
CerescanRxRevuSymbiaAllergySolutions<br/>Receivedincomeinanamountequaltoorgreater
than$250from:Symbia<br/>ReceivedfromAllergySolutions,IncforboardmembershipReceived
honorariafromRxRevuforchiefmedicaleditorReceivedsalaryfromMedvoyforfounderand
presidentReceivedconsultingfeefromCorvectraforseniormedicaladvisorReceivedownership
interestfromCerescanforconsultingReceivedconsultingfeefromEssiahealthforadvisor
ReceivedconsultingfeefromCarespanforadvisorReceivedconsultingfeefromCovidienfor
consulting.
Acknowledgements
KarinSChase,MDAssistantClinicalInstructorandResidentPhysician,Departmentof
EmergencyMedicine,StateUniversityofNewYorkDownstateMedicalCenter/KingsCounty
Hospital
KarinSChase,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,
andEmergencyMedicineResidentsAssociation
Disclosure:Nothingtodisclose.
ChristopherIDoty,MD,FACEP,FAAEMAssistantProfessorofEmergencyMedicine,Residency
ProgramDirector,DepartmentofEmergencyMedicine,KingsCountyHospitalCenter,State
UniversityofNewYorkDownstateMedicalCenter
ChristopherIDoty,MD,FACEP,FAAEMisamemberofthefollowingmedicalsocieties:American
AcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedical
Association,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
GerardJGianoli,MDClinicalAssociateProfessor,DepartmentofOtolaryngologyHeadandNeck
Surgery,TulaneUniversitySchoolofMedicineVicePresident,TheEarandBalanceInstitute
ChiefExecutiveOfficer,PonchartrainSurgeryCenter
GerardJGianoli,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
OtolaryngologyHeadandNeckSurgery,AmericanCollegeofSurgeons,AmericanNeurotology
Society,AmericanOtologicalSociety,SocietyofUniversityOtolaryngologistsHeadandNeck
Surgeons,andTriologicalSociety
Disclosure:Vesticon,Inc.NoneBoardmembership
AlyssaKHamman,MDResearchAssistant,DivisionofEmergencyMedicine,StanfordUniversity
AlyssaKHamman,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeof
ObstetriciansandGynecologists,AmericanMedicalAssociation,andColoradoMedicalSociety

Disclosure:Nothingtodisclose.
EricMKardon,MD,FACEPAttendingEmergencyPhysician,GeorgiaEmergencyMedicine
SpecialistsPhysician,DivisionofEmergencyMedicine,AthensRegionalMedicalCenter
EricMKardon,MD,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians
Disclosure:Nothingtodisclose.
JohnCLi,MDPrivatePracticeinOtologyandNeurotologyMedicalDirector,BalanceCenter
JohnCLi,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
OtolaryngologyHeadandNeckSurgery,AmericanCollegeofSurgeons,AmericanMedical
Association,AmericanNeurotologySociety,AmericanTinnitusAssociation,FloridaMedical
Association,andNorthAmericanSkullBaseSociety
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDSeniorPharmacyEditor,eMedicine
Disclosure:eMedicineSalaryEmployment
Jeter(Jay)PritchardTaylorIII,MDComplianceOfficer,AttendingPhysician,Emergency
MedicineResidency,DepartmentofEmergencyMedicine,PalmettoHealthRichland,Universityof
SouthCarolinaSchoolofMedicineMedicalDirector,DepartmentofEmergencyMedicine,
PalmettoHealthBaptist
Jeter(Jay)PritchardTaylorIII,MDisamemberofthefollowingmedicalsocieties:American
AcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedical
Association,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
NEwenWang,MDConsultingStaff,DepartmentofSurgery,DivisionofEmergencyMedicine,
StanfordUniversityHospital
Disclosure:Nothingtodisclose.
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