Mastoiditis

Background

Cross sectional ear anatomy (left).

Inflammation of middle ear spreads into mastoid air cells via the "aditus ad antrum"
Vast majority of acute mastoiditis occurs as a result of, or simultaneous with, acute otitis media
- Mastoiditis is unlikely if middle ear examination is normal

Etiology

Mastoiditis with subperiostal abscess

Clinical Features

Abnormal TM findings
Abnormal mastoid findings
- Erythema, edema, tenderness
Abnormal pinna findings
- Protrusion of auricle, obliteration of postauricular crease
Cranial nerve VI and VII palsies

Differential Diagnosis

Ear Diagnoses

External

Auricular hematoma
Auricular perichondritis
Cholesteatoma
Contact dermatitis
Ear foreign body
Herpes zoster oticus (Ramsay Hunt syndrome)
Malignant otitis externa
Otitis externa
Otomycosis
Tympanic membrane rupture
- Otic barotrauma

Internal

Inner/vestibular

Evaluation

CT scan: Otitis media (single arrow) and mastoiditis (double arrow) of the right side (left side in image). The external auditory canal is partially occupied by suppuration (triple arrow).

Middle ear fluid cultures
CT mastoid with IV contrast
- 90% sensitive
- Delineates extent of bony involvement
- Helps to diagnosis abscess formation

Management

ENT consultation - cases refractory to parenteral antibiotics may require surgical irrigation and debridement with possible mastoidectomy.

Coverage against S. pneumoniae, S. pyogenes, S. aureus, H. influenzae

Clindamycin 600mg IV q8 hours OR (if MRSA concern use Vancomycin regimen)
Vancomycin 15-20mg/kg IV q12 hours PLUS
- Ceftriaxone 1g (50mg/kg) IV once daily OR
- Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hours
If chronic or severe, need pseudomonas coverage
- Vanco + Piperacillin-tazobactam (Zosyn) 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose)

Disposition

Admit

Complications

Include, but are not limited to:

References

Authors: