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ORIGINAL ARTICLE
Ear, Nose and Throat Dept., Cairo University Hospital, Cairo, Egypt
KEYWORDS Abstract Mastoiditis remains a problem in Egypt. Despite the widespread use of antibiotics for otitis
Mastoiditis; media, many patients still present with complications.
Mastoid abscess; Treatment options for mastoiditis vary from simple incision and drainage of the tympanic mem-brane
Otitis media; to radical mastoidectomy.
Management; There seems to be no unanimous agreement on the best management strategy for this problem.
Guidelines In this study, we will review various management protocols for mastoiditis and mastoid abscess.
Along with our experience with 12 cases of mastoiditis and mastoid abscess, we will propose our own
management guidelines summarized in an easily accessible flowchart.
ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences.
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According to Dudkiewicz et al., the incidence of acute mas- – Definitive surgery: cortical, radical or modified radical mas-
toiditis in patients with acute otitis media (AOM) has dropped toidectomy was performed according to pathology, patient
from 50% at the turn of the 20th century to 6% in 1955 and to presentation and age.
0.4% in 1959, by 1993, only 0.24% of patients with acute otitis
media (AOM) developed acute mastoiditis.1 The Patients were followed up after 1, 3 and 6 months.
Petersen et al. reported a decline in the incidence of acute
mastoiditis from 20% in 1938 to 2.5% in 1945. Acute mastoid-itis 3. Results
has become rare, approaching 0%. It is, however, uncertain
whether this is directly associated with the antibiotics or if an
Patients were classified according to their presentation into the
altered nature of the disease/microorganisms and/or the state of following groups:
health is involved.4
There is evidence that the incidence of acute mastoiditis has 1- Cases with mastoid abscess: There were nine cases; these
recently been rising again; this phenomenon could be due to the cases were classified according to aetiopathology into the
increasing antibiotic resistance of microorganisms like following groups.
Streptococcus to penicillin.5 a. Acute otitis media: There were three cases. Two of
Streptococcus pneumoniae, Streptococcus pyogenes, Staphy- them were below 5 years of age. These patients pre-
lococcus aureus and Haemophilus influenzae are the most com- sented with antritis (Fig. 1) since the mastoid pro-cess
mon organisms recovered in acute mastoiditis. Pseudomonas is not fully pneumatized at this age, they were treated
aeruginosa, Enterobacteriaceae and S. aureus are the predomi- with medical treatment in addition to incision and
nant isolates that have been recovered from chronically inflamed drainage of the abscess. The third case received
mastoids. The role of P. aeruginosa in many of these cases is medical treatment followed by cortical
questionable because it colonizes the external ear canal and can mastoidectomy.
contaminate specimens obtained through the non-sterile ear canal.
Some reports described the recovery of anaerobes, including b. Cholesteatoma: There were five cases, two of them
presented with a complication (one with sigmoid sinus
Bacteroides species, from cases of chronic mastoiditis in
thrombosis and the other with an extradural abscess).
children.6 All cases were treated with open mastoid-ectomy in
addition to the treatment of the compli-cation in the
2. Materials and methods two complicated cases.
c. Safe chronic suppurative otitis media: We saw one
This study was conducted on patients who presented with mas- case which was treated with medical treatment in
toiditis or mastoid abscess to the ENT Department at Cairo addition to incision and drainage of the abscess. Later
University Hospital between June 2007 and June 2009. One on after acute inflammation had subsided,
patient presented with a mastoid abscess and postauricular fis-tula tympanoplasty with cortical mastoidectomy was
but was lost to follow up. performed.
This study included 12 patients, 8 males and 4 females. The
age ranged between 2 and 23 years with a mean age of 11.5 years. 2- Cases with mastoiditis: There were three cases; they were
All the patients were subjected to the following assessment classified according to aetiopathology into the following
protocol: groups.
a. Acute otitis media: There were two cases. One of
1. Full otologic examination. them was complicated with facial nerve paralysis and
2. Culture and sensitivity obtained for patients who did not was treated with cortical mastoidectomy and
receive previous antibiotic therapy.
3. CT scan, in cases of a suspected complication, MRI was
performed.
4. Neurosurgical consultation when needed to exclude any
intracranial complications.
4. Discussion
3. CT scan (Fig. 2) is considered the imaging modality of choice Diagnosis of acute coalescent mastoiditis.
for patients with acute mastoiditis. CT images should be Failure of medical therapy programme despite ade-
obtained in every patient with acute mastoiditis. If a compli- quate antibiotic treatment for 48–72 h.
cation is detected, MRI should follow. CT should be repeated Otorrhoea persisting for more than 2 weeks despite
if improvement is inadequate or incomplete and to detect any adequate antibiotic treatment.
complications that may arise during hospitalization Cholesteatoma.
4. The diagnosis should be made with cooperation between the
clinical pathology department, the radiodiagnosis team and if b. Methods:
required, neurosurgical consultation to exclude any
intracranial complication. 1. Minimally invasive procedures:
a. Incision and drainage of the mastoid abscess: Incision and
5.2. Treatment guidelines drainage (I&D) should be performed as soon as fluctuation
appears. The incision should be in line with any future
1. Medical treatment: surgical incisions. Hilton’s method is used to open all the
a. Indications: abscess loculi and to achieve complete drainage of the pus.
Absence of toxic appearance or signs of intracranial A pack of gauze soaked with Beta-dine can be placed in
involvement that point towards complicated mastoiditis. the abscess cavity and changed daily with wound nursing.
Myringotomy is needed in cases with insufficient drain-age 3. Acute mastoiditis with postauricular abscess.
e.g. intact drum or small high perforation. Treatment is surgical in the form of cortical mastoidec-
Treatment of the cause e.g. acute suppurative otitis media tomy after medical preparation with intravenous
antibiotics.
In unfavourable circumstances, the abscess may be inc-
2. Acute coalescent mastoiditis presenting with a complication ised and drained followed a few days later by
e.g. facial nerve paralysis or intracranial complications e.g. mastoidectomy.
lateral sinus thrombophlebitis. Treatment of the cause.
Treatment is mainly surgical under cover of broad spec-
trum intravenous antibiotics. 4. Acute mastoiditis complicating safe type of chronic suppu-
Treatment of the cause. rative otitis media.
Intracranial complications such as brain abscess or Medical treatment similar to acute suppurative otitis
meningitis should be co-managed with the neurosur-gery media.
department with priority going to the neurosurgery. When Treatment of the cause after the abscess has resolved e.g.
the patient is neurologically stable, management of the ear tympanoplasty with cortical mastoidectomy.
disease can be addressed.
If ICC detected by
MRI CT scan
CT or positive
neurological signs
Neurosurgical intervention
• Mastoid destruction • No Mastoid destruction
• Cholesteatoma • No Cholesteatoma
• Toxic appearance • No Toxic appearance
Co-Management
Mastoidectomy Mastoidectomy
Follow-up
48 M. Abdel Raouf et al.
5. Acute mastoiditis on top of unsafe type of chronic suppura- [3]. Holt GR, Gates GA. Masked mastoiditis. Laryngoscope.
tive otitis media (cholesteatoma). 1983;93:1034–1037.
Treatment is surgical in the form of open mastoidec-tomy [4]. Petersen CG, Ovesen T, Pedersen CB. Acute mastoidectomy in a
Danish county from 1977 to 1996 with focus on the bacteriology. Int J
under cover of intravenous broad spectrum antibiotic.
Pediatr Otorhinolaryngol. 1998;45:21–29.
[5]. Tarantino V, D’Agostino R, Taborelli G, Melagrana A, Porcu A, Stura
M. Acute Mastoiditis: a 10 year retrospective study. Int J Pediatr
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