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| {{Infobox_Disease
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| | Caption = Side view of head, showing surface relations of bones. (Mastoid process labeled near center.)
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| | DiseasesDB = 22479
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| {{Search infobox}}
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| {{CMG}} | | {{CMG}}; {{AE}}{{MJ}} |
| | {{Mastoiditis}} |
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| ==Overview==
| | {{SK}} Mastoid inflammation, Mastoid empyema, Inflammation of mastoid |
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| '''Mastoiditis''' is an infection of the [[mastoid process]], the portion of the [[temporal bone]] of the [[skull]] that is behind the [[ear]]. It is usually caused by untreated acute [[otitis media]] (middle ear infection) and used to be a leading cause of child mortality. With the development of [[antibiotic]]s, however, mastoiditis has become quite rare in developed countries, most likely due to antibiotic treatment of otitis media before it can spread. It is treated with medications and/or surgery. If untreated, the infection can spread to surrounding structures, including the [[brain]], causing serious complications.
| | ==[[Mastoiditis overview|Overview]]== |
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| ==Epidemiology== | | ==[[Mastoiditis historical perspective|Historical Perspective]]== |
| In the United States and other developed countries, the [[incidence (epidemiology)|incidence]] of mastoiditis is quite low, around 0.004%, although it is higher in developing countries. The most common ages affected are 6–13 months, as it is during that age that ear infections are most common. Males and females are equally affected.
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| ==Pathophysiology== | | ==[[Mastoiditis classification|Classification]]== |
| The pathophysiology of mastoiditis is straightforward: bacteria spread from the middle ear to the mastoid air cells, where the inflammation causes damage to the bony structures. The bacteria most commonly observed to cause mastoiditis are ''[[Streptococcus pneumoniae]]'', ''[[Streptococcus pyogenes]]'', ''[[Staphylococcus aureus]]'', and [[gram-negative]] [[bacilli]]. Other bacteria include ''[[Moraxella catarrhalis]]'', ''[[Streptococcus pyogenes]]'', and rarely, ''[[Mycobacterium]]'' species. Some mastoiditis is caused by [[cholesteatoma]], which is a sac of keratinizing squamous epithelium in the middle ear that usually results from repeated middle-ear infections. If left untreated, the cholesteatoma can erode into the mastoid process, producing mastoiditis, as well as other complications.
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| ==Symptoms and Signs== | | ==[[Mastoiditis pathophysiology|Pathophysiology]]== |
| Some common [[symptoms]] and signs of mastoiditis include pain and tenderness in the mastoid region, as well as swelling. There may be ear pain ([[otalgia]]), and the ear or mastoid region may be red (erythematous). Fever or headaches may also be present. Infants usually show nonspecific symptoms, such as [[anorexia (symptom)|anorexia]], [[diarrhea]], or [[irritability]]. Drainage from the ear occurs in more serious cases.
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| ==Diagnosis== | | ==[[Mastoiditis causes|Causes]]== |
| The diagnosis of mastoiditis is clinical—based on the [[medical history]] and [[physical examination]]. Imaging studies may provide additional information; the study of choice is the [[CT scan]], which may show focal destruction of the bone or signs of an [[abscess]] (a pocket of infection). [[X-rays]] are not as useful. If there is drainage, it is often sent for [[microbiological culture|culture]], although this will often be negative if the patient has begun taking antibiotics.
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| | ==[[Differentiating mastoiditis from other diseases|Differentiating Mastoiditis from other Diseases]]== |
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| ==Treatment== | | ==[[Mastoiditis epidemiology and demographics|Epidemiology and Demographics]]== |
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| The primary treatment for acute mastoiditis without [[osteitis]] is the administration of [[intravenous]] antibiotics. Initially, broad-spectrum antibiotics with activity against [[ Streptococcus pneumoniae|S. pneumoniae]] and [[ Haemophilus influenzae |H. influenzaeare]] are given. As culture results become available, treatment can be switched to more specific antibiotics. In cases with prolonged duration of mastoiditis, [[S. aureus]] and gram-negative enteric bacilli coverage may be considered for initial therapy until cultures results become available.<ref>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref> Antibiotics regimen of choice are similar to those for [[otitis media|acute otitis media]], and they are as follows:<ref name="pmid18092706">{{cite journal| author=Ramakrishnan K, Sparks RA, Berryhill WE| title=Diagnosis and treatment of otitis media. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 11 | pages= 1650-8 | pmid=18092706 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18092706 }} </ref><ref>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref>
| | ==[[Mastoiditis risk factors|Risk Factors]]== |
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| {| style="background: #FFFFFF;"
| | ==[[Mastoiditis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| {| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Antibiotics Used in the Treatment of Mastoiditis}}
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amoxicillin]] 80 to 90 mg per kg per day, given orally in two divided doses'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Recurrent or persistent acute mastoiditis, those used amoxicillin, or antibiotics within the previous month, or with concurrent purulent conjunctivitis'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amoxicillin-clavulanate]] 90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''For patients with penicillin allergy'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 30 mg per kg, given orally one dose'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''For recurrent Mastoiditis'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 20 mg per kg once daily, given orally x 3 days'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''For penicillin allergy type 1 hypersensitivity'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 5 to 10 mg per kg once daily, given orally x 5 days'''''
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''For patients with penicillin allergy excluding type 1 hypersensitivity'''''
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| | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefdinir]] 14 mg per kg per day, given orally in one or two doses'''''<BR>''OR''<BR>▸ '''''[[Cefpodoxime]] 30 mg per kg once daily, given orally'''''<BR>''OR''<BR>▸ '''''[[Ceftriaxone]] 50 mg per kg once daily, IM or IV. One dose for initial episode of otitis media, three doses for recurrent infections'''''<BR>''OR''<BR>▸ '''''[[Cefuroxime]] 30 mg per kg per day, given orally in two divided doses'''''<BR>''OR''<BR>▸ '''''[[Clarithromycin]] 15 mg per kg per day, given orally in three divided doses'''''<BR>''OR''<BR>▸ '''''[[Clindamycin]] 30 to 40 mg per kg per day, given orally in four divided doses'''''
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| Long-term antibiotics may be necessary to completely eradicate the infection. If the condition does not quickly improve with antibiotics, or is associated with osteitis, surgical procedures may be performed (while continuing the medication). The most common procedure is a [[myringotomy]], a small incision in the [[tympanic membrane]] (eardrum), or the insertion of a [[tympanostomy tube]] into the eardrum. These serve to drain the pus from the middle ear, helping to treat the infection. The tube is extruded spontaneously after a few weeks to months, and the incision heals naturally. If there are complications, or the mastoiditis does not respond to the above treatments, it may be necessary to perform a [[mastoidectomy]] in which a portion of the bone is removed and the infection drained.
| | ==Diagnosis== |
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| <div align="center">
| | [[Mastoiditis history and symptoms|History and Symptoms]] | [[Mastoiditis physical examination|Physical Examination]] | [[Mastoiditis laboratory findings|Laboratory Findings]] | [[Mastoiditis x ray|X ray]] | [[Mastoiditis CT|CT scan]] | [[Mastoiditis MRI|MRI]] | [[Mastoiditis ultrasound|Ultrasound]] | [[Mastoiditis other imaging findings|Other Imaging Findings]] | [[Mastoiditis other diagnostic studies|Other Diagnostic Studies]] |
| <gallery heights="125" widths="200">
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| Image:Mastoidectomy Arrowheads LABELED.jpg|Picture of a right mastoidectomy, surgeon's view. Note the blue color of the skeletonized sigmoid sinus.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy labeled1.jpg|Picture of a left mastoidectomy, surgeon's view.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy labeled.jpg|In this left canal wall up mastoidectomy, the tympanic membrane has been elevated forward and a cholesteatoma sac is visible in the attic.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoid cutaneous fistula trim.jpg|This patient has a recurrent cholesteatoma which has found its way to the surface of the post-auricular skin, forming a mastoid cutaneous fistula.<ref>http://www.ghorayeb.com</ref>
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| Image:Cholesteatoma sac eroding mastoid.jpg|This cholesteatoma sac has eroded the lateral surface of the mastoid bone and was found immediately under the post-auricular skin.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy Bowl.jpg|Left canal wall down mastoidectomy.This patient had a modified radical mastoidectomy with tympanoplasty. The posterior bony canal has been removed and part of the dry "mastoid bowl" is visible posterior and superior to the reconstructed tympanic membrane <ref>http://www.ghorayeb.com</ref>.
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| Image:Mastoidectomy Bowl 008.jpg|Magnification of the previous picture <ref>http://www.ghorayeb.com</ref>.
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| </gallery>
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| </div>
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| ==Prognosis== | | ==Treatment== |
| With prompt treatment, it is possible to cure mastoiditis. Seeking medical care early is important. However, it is difficult for antibiotics to penetrate to the interior of the mastoid process and so it may not be easy to cure the infection; it also may recur. Mastoiditis has many possible complications, all connected to the infection spreading to surrounding structures. [[Hearing loss]] may result, or inflammation of the [[labyrinth (inner ear)|labyrinth]] of the [[inner ear]] ([[labyrinthitis]]) may occur, producing [[Vertigo_(medical)|vertigo]]. The infection may also spread to the [[facial nerve]] (cranial nerve VII), causing [[facial-nerve palsy]] which can produce weakness or paralysis of some facial muscles on that side of the face. Other complications include [[Bezold's abscess]], an abscess (a collection of pus surrounded by inflamed tissue) behind the [[sternocleidomastoid muscle]] in the neck, or a subperiosteal abscess, between the periosteum and mastoid bone ( resulting in the typical appearance of a protruding ear). Serious complications result if the infection spreads to the brain. These include [[meningitis]] (inflammation of the protective membranes surrounding the brain), [[epidural abscess]] (abscess between the skull and outer membrane of the brain), dural venous [[thrombophlebitis]] (inflammation of the [[vein|venous]] structures of the brain), or [[brain abscess]].
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| ==Prevention==
| | [[Mastoiditis medical therapy|Medical Therapy]] | [[Mastoiditis surgery|surgery]] | [[Mastoiditis primary prevention|Primary Prevention]] | [[Mastoiditis secondary prevention|Secondary Prevention]] | [[Mastoiditis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Mastoiditis future or investigational therapies|Future or Investigational Therapies]] |
| In general, mastoiditis is rather simple to prevent. If the patient with an ear infection seeks treatment promptly and receives complete treatment, the antibiotics will usually cure the infection and prevent its spread. For this reason, mastoiditis is rare in developed countries.
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| ==References== | | ==References== |
| *Durand, Marlene & Joseph, Michael. (2001). Infections of the Upper Respiratory Tract. In Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, & J. Larry Jameson (Eds.), ''Harrison's Principles of Internal Medicine'' (15th Edition), p. 191. New York: McGraw-Hill
| | {{Reflist|2}} |
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| *"[http://www.nlm.nih.gov/medlineplus/ency/article/001034.htm Mastoiditis]" (July 30, 2003). MedlinePlus Medical Encyclopedia.
| | {{Diseases of the ear and mastoid process}} |
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| *Young, Tesfa. (June 10, 2005). "[http://www.emedicine.com/emerg/topic306.htm Mastoiditis]." eMedicine.
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| *http://www.ghorayeb.com
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| {{Diseases of the ear and mastoid process}} | |
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| [[Category:Skeletal disorders]]
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| [[Category:Inflammations]] | | [[Category:Inflammations]] |
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| | [[Category:Infectious disease]] |
| [[Category:Surgery]] | | [[Category:Surgery]] |
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