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==Overview==
==Overview==
Mastoiditis is the infection of [[mastoid air cells]] in the process of [[temporal bone]]. It is mostly a complication of ear diseases such as [[acute otitis media]] and [[chronic otitis media]], and it tends to occur in children. However after development of [[antibiotics]], [[acute otitis media]] complications have decreased significantly.
Mastoiditis is the [[infection]] of [[mastoid air cells]] in the process of [[temporal bone]]. It is mostly a complication of ear diseases such as [[acute otitis media]] and [[chronic otitis media]], and it tends to occur in children. However after development of [[antibiotics]], [[acute otitis media]] complications have decreased significantly.


== Historical perspective ==
== Historical perspective ==
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== Classification ==
== Classification ==
Mastoiditis may be classified into acute ,subacute and chronic forms, depending on the timing of presentation and duration.
Mastoiditis may be classified into acute, subacute, and chronic forms, depending on the timing of presentation and duration.


==Pathophysiology==
==Pathophysiology==
Mastoiditis is the infection in the cavities of [[mastoid process]] of [[temporal bone]] that occurs after [[otitis media]]. At birth, the [[mastoid]] consists of a single cavity, which is connected to the [[middle ear]] by a canal. As the child grows, the [[mastoid bone]] becomes pneumatized, resulting in a series of connected cavities, lined by a [[mucosa]] diverted from respiratory epithelium. There is a relationship between the [[middle ear]], [[eustachian tube]], and the [[mastoid]]. This connection has a fundamental role in the pathogenesis of mastoiditis. In the setting of [[acute otitis media]] the [[mucosa]] that lines the middle ear and also [[mastoid air cells]] becomes inflamed. In majority cases of [[acute otitis media]] inflammation resolves, but some persist leading to bacterial and fluid accumulation within the [[mastoid air cells]]. Gradually, as a result of pressure rising in the [[mastoid]], air cell septae may be destroyed and mastoiditis could be proceed to [[osteomyelitis]]. Mastoid is near vital organs in head and neck and mastoid infection may cause serious complications. There is evidence of genetic predisposition to recurrent otitis media and therefore mastoiditis. The following genes have been identified as having potential pathogenic qualities for [[otitis media]]: CAPN14, GALNT14, BPIFA3, BPIFA1, [[BMP5]], GALNT13, [[NELL1]], TGFB3.
Mastoiditis is the infection in the cavities of [[mastoid process]] of [[temporal bone]] that occurs after [[otitis media]]. At birth, the [[mastoid]] consists of a single cavity, which is connected to the [[middle ear]] by a canal. As the child grows, the [[mastoid bone]] becomes pneumatized, resulting in a series of connected cavities, lined by a [[mucosa]] diverted from [[respiratory epithelium]]. There is a relationship between the [[middle ear]], the [[eustachian tube]], and the [[mastoid]]. This connection has a fundamental role in the pathogenesis of mastoiditis. In the setting of [[acute otitis media]], the [[mucosa]] that lines the [[middle ear]] and [[mastoid air cells]] become inflamed. In most cases of [[acute otitis media]], [[inflammation]] resolves, but it sometimes persists, leading to bacterial and fluid accumulation within the [[mastoid air cells]]. Gradually, as a result of pressure rising in the [[mastoid]], air cell septae may be destroyed and mastoiditis could proceed to [[osteomyelitis]]. The mastoid is near vital organs in the head and neck and mastoid [[infection]] may cause serious complications. There is evidence of genetic predisposition to recurrent [[otitis media]] and therefore mastoiditis. The following [[genes]] have been identified as having potential pathogenic qualities for [[otitis media]]: CAPN14, GALNT14, BPIFA3, BPIFA1, [[BMP5]], GALNT13, [[NELL1]], and TGFB3.


==Causes==
==Causes==
Mastoiditis results from middle ear infection. The most common bacteria that cause acute mastoiditis are [[Streptococcus pneumoniae]], [[Streptococcus pyogenes]], and [[Staphylococcus aureus]]. [[Staphylococci]], [[Pseudomonas]] species and polymicrobials predominantly seen in non-acute [[mastoiditis]]. [[Pseudomonas aeruginosa]] may be found in children with acute [[mastoiditis]] as a consequence of recurrent [[acute otitis media]] and antibiotic use.
Mastoiditis results from [[middle ear]] [[infection]]. The most common bacteria that cause acute mastoiditis are [[Streptococcus pneumoniae|''Streptococcus pneumoniae'']], [[Streptococcus pyogenes|''Streptococcus pyogenes'']], and [[Staphylococcus aureus|''Staphylococcus aureus'']]. [[Staphylococci|''Staphylococci'']], [[Pseudomonas|''Pseudomonas'']] species, and polymicrobials are predominantly seen in non-acute [[mastoiditis]]. [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']] may be found in children with acute [[mastoiditis]] as a consequence of recurrent [[acute otitis media]] and antibiotic use.


== Differentiating Mastoiditis from other Diseases==
== Differentiating Mastoiditis from other Diseases==
Mastoiditis must be differentiated from other diseases that cause [[Postauricular inflammation and swelling|postauricular inflammation or swelling]] such as [[lymphadenopathy]], periauricular [[cellulitis]], [[auricle]] perichondritis, [[mumps]] and [[mastoid]] [[tumors]]. These diseases may be distinguished from mastoiditis via clinical findings and laboratory testing.
Mastoiditis must be differentiated from other diseases that cause [[Postauricular inflammation and swelling|postauricular inflammation or swelling]] such as [[lymphadenopathy]], periauricular [[cellulitis]], [[auricle]] perichondritis, [[mumps]], and [[mastoid]] [[tumors]]. These diseases may be distinguished from mastoiditis via clinical findings and laboratory testing.


==Epidemiology and Demographics==
==Epidemiology and Demographics==
Mastoiditis [[incidence]] is 1.2–6.1 per 100,000 inhabitants in developed countries. Serious progressions appear more frequently in young children. After using [[pneumococcal]] [[vaccination]], the rate of acute [[otitis media]] and mastoiditis decreased dramatically. However, there is a concern about rising [[incidence]], which is connected to inadequate [[antibiotic]] dosing in [[otitis media]], choice of [[antibiotics]], and increasing [[resistance]] of bacteria. Acute mastoiditis is most common in children under two years of age. Men and women are affected equally by mastoiditis. [[Otitis media]] and therefore mastoiditis, is most prevalent in developing countries, specifically Sub-Saharan West Africa, Southeast Asia, and Oceania. Risk factors that may contribute to higher [[incidence]] in developing countries are: exposure to [[HIV]], [[malnutrition]], large proportion of children under 5 years , in the population and higher chance of water [[Contamination|contamination.]]
Mastoiditis [[incidence]] is 1.2–6.1 per 100,000 inhabitants in developed countries. Serious progressions appear more frequently in young children. After using [[pneumococcal]] [[vaccination]], the rate of acute [[otitis media]] and mastoiditis decreased dramatically. However, there is a concern about rising [[incidence]], which is connected to inadequate [[antibiotic]] dosing in [[otitis media]], choice of [[antibiotics]], and increasing [[resistance]] of bacteria. Acute mastoiditis is most common among children under two years of age.<ref name="pmid228322392">{{cite journal|year=2012|title=Acute mastoiditis in children aged 0-16 years--a national study of 678 cases in Sweden comparing different age groups|url=|journal=Int. J. Pediatr. Otorhinolaryngol.|volume=76|issue=10|pages=1494–500|doi=10.1016/j.ijporl.2012.07.002|pmid=22832239|vauthors=Groth A, Enoksson F, Hultcrantz M, Stalfors J, Stenfeldt K, Hermansson A}}</ref> Men and women are affected equally by mastoiditis. [[Otitis media]] and therefore mastoiditis are more prevalent in developing countries, specifically Sub-Saharan West Africa, Southeast Asia, and Oceania. Risk factors that may contribute to higher incidence in developing countries include exposure to [[HIV]], [[malnutrition]], a large proportion of children under 5 years in the population, and higher chance of water [[Contamination|contamination.]]


== Risk Factors ==
== Risk Factors ==
The risk factors for [[mastoiditis]] are related to [[acute otitis media]] risk factors. Risk factors are [[allergy]], [[upper respiratory tract infection]], [[snoring]], previous history of [[acute otitis media]], passive smoking, mother [[smoking]] during pregnancy, low social status. Exposure of infants to day-care centers is a controversial risk factor.
The risk factors for [[mastoiditis]] are related to [[acute otitis media]] risk factors. Risk factors are [[allergy]], [[upper respiratory tract infection]], [[snoring]], previous history of [[acute otitis media]], passive smoking, mother [[smoking]] during pregnancy, and low social status. Exposure of infants to day-care centers is a controversial risk factor.


== Screening ==
== Screening ==
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== Natural History, Complications and Prognosis ==
== Natural History, Complications and Prognosis ==
Without treatment, [[mastoiditis]] will result in complications such as intracranial extension and permanent neurological deficits or death.The consequences of [[mastoiditis]] have been reduced after introduction of [[antimicrobial]] agents and adequate therapy of [[acute otitis media]]. However, [[mastoiditis]] has not been eradicated completely and may give rise to severe complications. These complications may be classified into extracranial such as [[osteomyelitis]], [[labyrinthitis]], [[facial nerve palsy]], [[Bezold's abscess]], [[hearing loss]], subperiosteal abscess or intracranial such as epidural and subdural abscess, [[meningitis]], [[temporal bone]] or [[brain abscess]] and [[venous sinus thrombosis]]. The prognosis of [[mastoiditis]] is good with treatment. Excellent outcomes may be expected for those who are managed without delay and patients recover without complications.
If left untreated, [[mastoiditis]] will result in severe complications such as intracranial extension and permanent neurological deficits or death. The consequences of [[mastoiditis]] have been reduced after introduction of [[antimicrobial]] agents and adequate therapy of [[acute otitis media]]. However, if [[mastoiditis]] is not eradicated completely, it may give rise to severe complications. These complications are extracranial, such as [[osteomyelitis]], [[labyrinthitis]], [[facial nerve palsy]], [[Bezold's abscess]], [[hearing loss]], [[subperiosteal]] [[abscess|abscess,]] or intracranial, such as [[epidural]] and [[subdural abscess]], [[meningitis]], [[temporal bone]] or [[brain abscess]] and [[venous sinus thrombosis]]. The prognosis of [[mastoiditis]] is good with treatment. Excellent outcomes can be expected for those who are managed without delay.


==Diagnosis==
==Diagnosis==


===History and Symptoms ===
===History and Symptoms ===
History and [[symptoms]] of mastoiditis ranges from non-symptomatic disease to [[symptomatic]] and progressive mastoiditis with serious life-threatening complications. Common symptoms of mastoiditis are [[ear pain]], [[fever]], feeling of "fullness" in the ear, recent episode of [[Acute otitis media|acute otitis media,]] fluid [[discharge]] in the ear, partial loss of hearing, [[irritability]] (in infants), [[headache]], [[lethargy]]/[[Malaise|malaise.]] [[Neurological]] symptoms from chronic mastoiditis and [[otitis media]] with effusion: poor attention span, delayed speech development, [[clumsiness]] and poor balance.
History and [[symptoms]] of mastoiditis range from [[asymptomatic]] disease to [[symptomatic]] and progressive mastoiditis with serious life-threatening complications. History should be taken considering onset, duration, and progression of symptoms, [[allergies]], previous history of [[acute otitis media]], [[upper respiratory tract infection]], associated symptoms ([[otalgia]], [[fever]], [[confusion]]), [[medications]] including [[antibiotic]] usage in [[Acute otitis media|acute otitis media,]] [[snoring]], attendance to day care, history of [[Trauma|trauma,]] co-morbid conditions like [[diabetes]], [[immunodeficiency]], and smoking. Common symptoms of mastoiditis are: [[ear pain]], [[fever]], feeling of "fullness" in the ear, recent episode of [[Acute otitis media|acute otitis media,]] [[discharge]] from the affected ear, partial hearing loss, [[irritability]] (in infants), [[headache]], and [[lethargy]]/[[Malaise|malaise.]] [[Neurological]] symptoms from chronic mastoiditis and [[otitis media]] with effusion include poor [[attention span]], delayed speech development, [[clumsiness]], and poor [[balance]]. Less common symptoms are gastrointestinal symptoms such as [[vomiting]] and [[diarrhea]], [[meningismus]], and [[torticollis]]


===Physical Examination===
===Physical Examination===
Mastoiditis physical examination include posterior auricular signs such as postauricular swelling, erythema, tenderness, protrusion of pinna, and sagging external ear canal. On [[Otoscopy|otoscopic]] examination of the [[middle ear]] include [[erythema]], bulging, cloud appearance, and immobility of the [[tympanic membrane]]. Partial [[hearing loss]] from fluid buildup is indicative of otitis media, revealed by [[tympanometry]]. Acute mastoiditis patients are usually ill-appearing and usually present with low-grade [[fever]] and complicated mastoiditis patients may present with severely ill appearance.
Mastoiditis physical examination includes posterior auricular signs such as postauricular [[swelling]], [[erythema]], [[tenderness]], protrusion of [[pinna]], and sagging external [[ear canal]]. [[Otoscopy|Otoscopic]] examination of the [[middle ear]] shows [[erythema]], bulging, cloudy appearance, and immobility of the [[tympanic membrane]]. Partial [[hearing loss]] from fluid buildup is indicative of [[otitis media]], revealed by [[tympanometry]]. Acute mastoiditis patients are usually ill-appearing and usually present with low-grade [[fever]], while complicated mastoiditis patients may present with severely ill appearance.


===Laboratory Findings===
===Laboratory Findings===
There are no diagnostic blood laboratory findings associated with mastoiditis. Some patients with mastoiditis may have elevated [[ESR]], [[CRP]] and [[white blood cells]] with a [[left shift]]. These laboratory findings are nonspecific and not helpful in making the diagnosis. It is very important to obtain clinical specimens for [[microbiology]]. Microbial results are crucial in the proper [[antimicrobial]] choice for treatment. There are multiple type of bacteria that may cause [[Mastoiditis causes|mastoiditis]] like [[Streptococcus|strep]] species and [[staphylococcus aureus]], and there is rising concerns about antibiotic [[resistance]] in some microorganisms. The obtained fluid or pus should be sent for [[Gram stain]], [[aerobic]] and [[anaerobic]] culture, and antimicrobial susceptibility testing. Specimens for mastoiditis treatment could be obtain via multiple sites such as middle ear via [[tympanocentesis]] or [[myringotomy]], [[percutaneous]] [[aspiration]] from subperiosteal [[abscess]], [[cerebrospinal fluid]], [[Blood culture|blood cultures]].
There are no diagnostic blood laboratory findings associated with mastoiditis. Some patients with mastoiditis may have elevated [[ESR]], [[CRP]], and [[white blood cells]] with a [[left shift]]. These laboratory findings are nonspecific and not helpful in making the diagnosis. It is very important to obtain clinical specimens for [[microbiology]]. Microbial results are crucial in the proper [[antimicrobial]] choice for treatment. There are multiple types of bacteria that may cause [[Mastoiditis causes|mastoiditis]] like ''[[Streptococcus]]'' species and [[staphylococcus aureus|''Staphylococcus aureus'']], and there are rising concerns about antibiotic [[resistance]] in some microorganisms. The obtained fluid or [[pus]] should be sent for [[Gram stain]], [[aerobic]] and [[anaerobic]] culture, and antimicrobial susceptibility testing. Specimens for mastoiditis treatment could be obtained via multiple sites such as [[middle ear]] via [[tympanocentesis]] or [[myringotomy]], [[percutaneous]] [[aspiration]] from subperiosteal [[abscess]], [[cerebrospinal fluid]], or [[Blood culture|blood cultures]].


===X ray===
===X-ray===
There are no diagnostic [[x ray]] findings associated with mastoiditis.
There are no diagnostic [[X-ray]] findings associated with mastoiditis.


===CT scan===
===CT scan===
[[High Resolution CT]] scans of the [[temporal bone]] in mastoiditis patients is the preferred diagnostic tool and may reveal mastoiditis and its complications. CT findings in acute mastoiditis are partial-to-complete opacification of mastoid air cells, erosion of mastoid air cell bony septum, mastoid cortex destruction and irregularity, periosteal thickening, periosteal disruption and subperiosteal abscess. CT findings in subacute and chronic mastoiditis are: markers for [[inflammation]], sclerosis or opacification of mastoid process, tympanic membrane changes such as thickening, retraction, tympanic membrane perforation or calcification; ossicle erosion or other possible causes for [[hearing loss]], determination of [[cholesteatoma]], intratemporal complications such as petrositis, [[labyrinthitis]], [[subperiosteal]] [[abscess]], labyrinthine [[Fistula|fistula;]] Intracranial complications such as [[brain abscess]], [[meningitis]]; presence of [[fibrous]] [[tissue]], tympanosclerosis, formation of new bone matter[[Ossicles|, ossicle]] erosion and displacement and extension of [[cholesteatoma]] to [[sinuses]].
[[High Resolution CT]] scans of the [[temporal bone]] in mastoiditis patients are the preferred diagnostic tool and may reveal mastoiditis and its complications. CT findings in acute mastoiditis are: partial-to-complete opacification of [[mastoid air cells]], erosion of [[Mastoid air cells|mastoid air cell]] bony septum, mastoid cortex destruction and irregularity, [[Periosteum|periosteal]] thickening, [[Periosteum|periosteal]] disruption, and subperiosteal [[abscess]]. CT findings in subacute and [[chronic]] mastoiditis are: markers for [[inflammation]], [[sclerosis]], or opacification of [[Mastoid process|mastoid process]], [[tympanic membrane]] changes including thickening, retraction, [[tympanic membrane perforation]], or calcification, [[Ossicles|ossicle]] erosion or other possible causes for [[hearing loss|hearing loss]], determination of [[cholesteatoma|cholesteatoma]], intratemporal complications such as petrositis, [[labyrinthitis]], [[subperiosteal]] [[abscess]], or labyrinthine [[Fistula|fistula]], intracranial complications such as [[brain abscess]] and [[meningitis]], presence of [[fibrous]] [[tissue]], tympanosclerosis, formation of new bone matter, [[Ossicles|ossicle]] erosion, and displacement and extension of [[cholesteatoma]] to [[sinuses]].


===MRI===
===MRI===
Both [[CT-scans|CT]] and [[MRI]] are used in the evaluation of mastoiditis and its complications. [[MRI]] in mastoiditis plays role in the detection of [[cholesteatoma]], also when intracranial and some intratemporal complications are suspected. Specifically, [[MRI]] has shown superiority in assessing the severity of intracranial involvement and [[abscess]] border visualization.  
Both [[CT-scans|CT]] and [[MRI]] are used in the evaluation of mastoiditis and its complications. [[MRI]] in mastoiditis plays a role in the detection of [[cholesteatoma]], also when intracranial and some intratemporal complications are suspected. Specifically, [[MRI]] has shown superiority in assessing the severity of intracranial involvement and [[abscess]] border visualization.  


===Ultrasound===
===Ultrasound===
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===Other Imaging Findings===
===Other Imaging Findings===
Other mastoiditis imaging findings include [[Otoscopy|otoscopic]] images of the [[tympanic membrane]] displaying middle ear effusion and infection. Also [[Tympanometry|tympanograms]] may be used for measuring pressure from fluid buildup in the [[middle ear]].
There are no other diagnostic findings for mastoiditis.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic findings for mastoiditis.
Other mastoiditis imaging findings include [[Otoscopy|otoscopic]] images of the [[tympanic membrane]] displaying [[middle ear]] effusion and [[infection]]. Also, [[Tympanometry|tympanograms]] may be used for measuring pressure from fluid buildup in the [[middle ear]].


==Treatment==
==Treatment==


===Medical Therapy===
===Medical Therapy===
Medical treatment for acute and subacute mastoiditis without intracranial complications is intravenous [[antibiotics]] and [[myringotomy]]. [[Antibiotics]] for acute mastoiditis must cover the most common bacterial pathogens: [[Streptococcus pneumoniae]], [[Streptococcus pyogenes]], and [[Staphylococcus aureus]] (including [[Methicillin-resistant staphylococcus aureus|methicillin-resistant ''S.'' aureus]]). If there is a history of recurrent [[acute otitis media]] or recent antibiotic usage the intravenous antibiotic also should cover the [[Pseudomonas aeruginosa]]. Bacteria commonly should cover are [[Streptococcus pneumonia]], [[Group A streptococcus]], [[Staphylococcus aureus]]. The empiric antibiotics are: [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] or [[ampicillin]]; add [[Vancomycin]] for severe infection with adjacent complications, or suspicion of [[MRSA]]. For chronic mastoiditis bacteria commonly should cover [[Pseudomonas aeruginosa]], [[Staphylococcus aureus]] and [[anaerobes]]. Antibiotics are [[Piperacillin-tazobactam]] or [[Piperacillin]], and [[Ofloxacin]] Otic Solution; add [[Vancomycin]] for severe infection with adjacent complications, or suspicion of [[MRSA]].  
Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous [[antibiotics]] and [[myringotomy]]. [[Antibiotics]] for acute mastoiditis must cover the most common bacterial pathogens: [[Streptococcus pneumoniae|''Streptococcus pneumoniae'']], [[Streptococcus pyogenes|''Streptococcus pyogenes'']], and [[Staphylococcus aureus|''Staphylococcus aureus'']] (including [[Methicillin-resistant staphylococcus aureus|methicillin-resistant ''S.'' ''aureus'']]). If there is a history of recurrent [[acute otitis media]] or recent antibiotic usage, the [[intravenous]] antibiotic also should cover [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']]. Bacteria commonly covered include [[Streptococcus pneumonia|''Streptococcus pneumonia'']], [[Group A streptococcus|Group A ''streptococcus'']], and [[Staphylococcus aureus|''Staphylococcus aureus'']]. The empiric antibiotics are [[Ampicillin-Sulbactam|ampicillin-sulbactam]] or [[ampicillin]]; add [[vancomycin]] for severe infection with adjacent complications or suspicion of [[MRSA]]. For [[chronic]] mastoiditis, bacteria commonly covered are [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']], [[Staphylococcus aureus|''Staphylococcus aureus'']] and [[anaerobes]]. Antibiotics include [[piperacillin-tazobactam]] or [[piperacillin]], and [[ofloxacin]] otic solution; add [[vancomycin]] for severe infection with adjacent complications or suspicion of [[MRSA]].  


===Surgery===
===Surgery===
Different [[surgical procedures]] may be done in mastoiditis. [[Myringotomy]] is surgical perforation of the [[tympanic membrane]]. It should be considered as a primary treatment in all cases of [[infectious]] mastoiditis following [[otitis media]], particularly when there is an unperforated [[tympanic membrane]] or inadequate drainage. [[Tympanocentesis]] should be done in all mastoiditis patients to obtain [[middle ear]] fluid for culture and susceptibility testing. [[Myringotomy]] accompanied by the additional insertion of a [[tympanostomy tube]] is indicated in some cases such as [[eustachian tube]] dysfunction, [[suppurative]] complication requiring additional drainage and repair the [[tympanic membrane]] from [[eustachian tube]] dysfunction. Definitive surgery is [[mastoidectomy]], which is the surgical removal of the [[mastoid]] cortical bone and underlying air cells. Indications for [[mastoidectomy]] may include: subperiosteal [[abscess]], such as postauricular fluctuance or mass; chronic [[suppurative]] [[otitis media]] or [[cholesteatoma]]; progression of postauricular swelling or fluctuance, [[fever]], and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and [[myringotomy]].
Different [[surgical procedures]] may be performed to treat mastoiditis. [[Myringotomy]] is surgical perforation of the [[tympanic membrane]]. It should be considered the primary treatment in all cases of [[infectious]] mastoiditis following [[otitis media]], particularly when there is an unperforated [[tympanic membrane]] or inadequate drainage. [[Tympanocentesis]] should be performed in all mastoiditis patients to obtain [[middle ear]] fluid for culture and susceptibility testing. [[Myringotomy]] accompanied by the additional insertion of a [[tympanostomy tube]] is indicated in some cases, such as [[Eustachian tube]] dysfunction, [[suppurative]] complications requiring additional drainage, and when [[tympanic membrane]] must be repaired from [[Eustachian tube dysfunction]]. Definitive surgery is [[mastoidectomy]], which is the surgical removal of the [[mastoid]] cortical bone and underlying [[Mastoid air cells|air cells]]. Indications for [[mastoidectomy]] may include subperiosteal [[abscess]] such as postauricular fluctuance or mass, [[chronic]] [[suppurative]] [[otitis media]] or [[cholesteatoma]], progression of postauricular swelling or fluctuance, [[fever]], and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and [[myringotomy]].


===Primary Prevention===
===Primary Prevention===
Preventing mastoiditis primarily involves preventing development of otitis media and [[nasopharyngitis]]. This is achieved by administration the [[pneumococcal]] and [[influenza]] [[vaccines]], frequently washing hands, and avoiding fluid transmission and respiratory droplets from [[nasopharyngitis]] patients. Preventing exposure to [[air pollution]] as potential [[middle ear]] irritants, such as secondhand smoke, contributes to preventing otitis media. For infants, preventative measures include avoiding pacifiers, avoiding daycare enrollment, and [[breastfeeding]] until at least 6 months of age. A [[prophylactic]] regimen of [[antibiotics]] can prevent [[otitis media]] in at-risk infants and children.
Preventing mastoiditis primarily involves preventing development of otitis media and [[nasopharyngitis]]. This is achieved by administration of the [[pneumococcal]] and [[influenza]] [[vaccines]], frequently washing hands, and avoiding fluid transmission and respiratory droplets from [[nasopharyngitis]] patients. Preventing exposure to [[air pollution]], as potential [[middle ear]] irritants such as secondhand smoke helps prevent otitis media, is also helpful in preventing mastoiditis. For infants, preventative measures include avoiding pacifiers, avoiding daycare enrollment, and [[breastfeeding]] until at least 6 months of age. A [[prophylactic]] regimen of [[antibiotics]] can prevent [[otitis media]] in at-risk infants and children.


===Secondary Prevention===
===Secondary Prevention===
For mastoiditis following chronic or [[recurrent otitis media]], preventing recurrence of the disease involves surgery, assuming the manifestation is not self-limited. [[Myringotomy]] with [[tympanostomy tube]] and [[mastoidectomy]] is the most common surgical preventative measure.
For mastoiditis following [[chronic]] or [[recurrent otitis media]], preventing recurrence of the disease involves surgery, assuming the manifestation is not self-limited. [[Myringotomy]] with [[tympanostomy tube]] and [[mastoidectomy]] is the most common surgical preventative measure.


==References==
==References==
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[[Category:Emergency mdicine]]
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[[Category:Infectious disease]]
[[Category:Otolaryngology]]
[[Category:Surgery]]

Latest revision as of 22:39, 29 July 2020

Mastoiditis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Mastoiditis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Overview

Mastoiditis is the infection of mastoid air cells in the process of temporal bone. It is mostly a complication of ear diseases such as acute otitis media and chronic otitis media, and it tends to occur in children. However after development of antibiotics, acute otitis media complications have decreased significantly.

Historical perspective

Mastoiditis was first described by Hippocrates in the 5th century B.C.E. The first recorded surgical incision for treatment of medial ear infection was in the 16th century C.E., performed by French physician Ambroise Pare. Initial therapies for middle ear diseases were surgical, particularly mastoidectomy, which was first performed by French physician Jean-Louis Petit in the 17th century C.E. German physicians Hermann Schwartze, Anton von Troltsch, and Adam Politzer published the first journal dedicated to ear pathology and treatment in 1865. Antibiotic therapy for mastoiditis treatment emerged with the invention of mass production of penicillin in 1940 by Alexander Fleming, Howard Florey, and Ernst Chain. The pneumococcal conjugate vaccine (PCV) emerged in 2000, greatly reducing the incidence of otitis media and mastoiditis by vaccinating individuals against the causative pathogens.

Classification

Mastoiditis may be classified into acute, subacute, and chronic forms, depending on the timing of presentation and duration.

Pathophysiology

Mastoiditis is the infection in the cavities of mastoid process of temporal bone that occurs after otitis media. At birth, the mastoid consists of a single cavity, which is connected to the middle ear by a canal. As the child grows, the mastoid bone becomes pneumatized, resulting in a series of connected cavities, lined by a mucosa diverted from respiratory epithelium. There is a relationship between the middle ear, the eustachian tube, and the mastoid. This connection has a fundamental role in the pathogenesis of mastoiditis. In the setting of acute otitis media, the mucosa that lines the middle ear and mastoid air cells become inflamed. In most cases of acute otitis media, inflammation resolves, but it sometimes persists, leading to bacterial and fluid accumulation within the mastoid air cells. Gradually, as a result of pressure rising in the mastoid, air cell septae may be destroyed and mastoiditis could proceed to osteomyelitis. The mastoid is near vital organs in the head and neck and mastoid infection may cause serious complications. There is evidence of genetic predisposition to recurrent otitis media and therefore mastoiditis. The following genes have been identified as having potential pathogenic qualities for otitis media: CAPN14, GALNT14, BPIFA3, BPIFA1, BMP5, GALNT13, NELL1, and TGFB3.

Causes

Mastoiditis results from middle ear infection. The most common bacteria that cause acute mastoiditis are Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. Staphylococci, Pseudomonas species, and polymicrobials are predominantly seen in non-acute mastoiditis. Pseudomonas aeruginosa may be found in children with acute mastoiditis as a consequence of recurrent acute otitis media and antibiotic use.

Differentiating Mastoiditis from other Diseases

Mastoiditis must be differentiated from other diseases that cause postauricular inflammation or swelling such as lymphadenopathy, periauricular cellulitis, auricle perichondritis, mumps, and mastoid tumors. These diseases may be distinguished from mastoiditis via clinical findings and laboratory testing.

Epidemiology and Demographics

Mastoiditis incidence is 1.2–6.1 per 100,000 inhabitants in developed countries. Serious progressions appear more frequently in young children. After using pneumococcal vaccination, the rate of acute otitis media and mastoiditis decreased dramatically. However, there is a concern about rising incidence, which is connected to inadequate antibiotic dosing in otitis media, choice of antibiotics, and increasing resistance of bacteria. Acute mastoiditis is most common among children under two years of age.[1] Men and women are affected equally by mastoiditis. Otitis media and therefore mastoiditis are more prevalent in developing countries, specifically Sub-Saharan West Africa, Southeast Asia, and Oceania. Risk factors that may contribute to higher incidence in developing countries include exposure to HIV, malnutrition, a large proportion of children under 5 years in the population, and higher chance of water contamination.

Risk Factors

The risk factors for mastoiditis are related to acute otitis media risk factors. Risk factors are allergy, upper respiratory tract infection, snoring, previous history of acute otitis media, passive smoking, mother smoking during pregnancy, and low social status. Exposure of infants to day-care centers is a controversial risk factor.

Screening

There is insufficient evidence to recommend routine screening for mastoiditis.

Natural History, Complications and Prognosis

If left untreated, mastoiditis will result in severe complications such as intracranial extension and permanent neurological deficits or death. The consequences of mastoiditis have been reduced after introduction of antimicrobial agents and adequate therapy of acute otitis media. However, if mastoiditis is not eradicated completely, it may give rise to severe complications. These complications are extracranial, such as osteomyelitis, labyrinthitis, facial nerve palsy, Bezold's abscess, hearing loss, subperiosteal abscess, or intracranial, such as epidural and subdural abscess, meningitis, temporal bone or brain abscess and venous sinus thrombosis. The prognosis of mastoiditis is good with treatment. Excellent outcomes can be expected for those who are managed without delay.

Diagnosis

History and Symptoms

History and symptoms of mastoiditis range from asymptomatic disease to symptomatic and progressive mastoiditis with serious life-threatening complications. History should be taken considering onset, duration, and progression of symptoms, allergies, previous history of acute otitis media, upper respiratory tract infection, associated symptoms (otalgia, fever, confusion), medications including antibiotic usage in acute otitis media, snoring, attendance to day care, history of trauma, co-morbid conditions like diabetes, immunodeficiency, and smoking. Common symptoms of mastoiditis are: ear pain, fever, feeling of "fullness" in the ear, recent episode of acute otitis media, discharge from the affected ear, partial hearing loss, irritability (in infants), headache, and lethargy/malaise. Neurological symptoms from chronic mastoiditis and otitis media with effusion include poor attention span, delayed speech development, clumsiness, and poor balance. Less common symptoms are gastrointestinal symptoms such as vomiting and diarrhea, meningismus, and torticollis

Physical Examination

Mastoiditis physical examination includes posterior auricular signs such as postauricular swelling, erythema, tenderness, protrusion of pinna, and sagging external ear canal. Otoscopic examination of the middle ear shows erythema, bulging, cloudy appearance, and immobility of the tympanic membrane. Partial hearing loss from fluid buildup is indicative of otitis media, revealed by tympanometry. Acute mastoiditis patients are usually ill-appearing and usually present with low-grade fever, while complicated mastoiditis patients may present with severely ill appearance.

Laboratory Findings

There are no diagnostic blood laboratory findings associated with mastoiditis. Some patients with mastoiditis may have elevated ESR, CRP, and white blood cells with a left shift. These laboratory findings are nonspecific and not helpful in making the diagnosis. It is very important to obtain clinical specimens for microbiology. Microbial results are crucial in the proper antimicrobial choice for treatment. There are multiple types of bacteria that may cause mastoiditis like Streptococcus species and Staphylococcus aureus, and there are rising concerns about antibiotic resistance in some microorganisms. The obtained fluid or pus should be sent for Gram stain, aerobic and anaerobic culture, and antimicrobial susceptibility testing. Specimens for mastoiditis treatment could be obtained via multiple sites such as middle ear via tympanocentesis or myringotomy, percutaneous aspiration from subperiosteal abscess, cerebrospinal fluid, or blood cultures.

X-ray

There are no diagnostic X-ray findings associated with mastoiditis.

CT scan

High Resolution CT scans of the temporal bone in mastoiditis patients are the preferred diagnostic tool and may reveal mastoiditis and its complications. CT findings in acute mastoiditis are: partial-to-complete opacification of mastoid air cells, erosion of mastoid air cell bony septum, mastoid cortex destruction and irregularity, periosteal thickening, periosteal disruption, and subperiosteal abscess. CT findings in subacute and chronic mastoiditis are: markers for inflammation, sclerosis, or opacification of mastoid process, tympanic membrane changes including thickening, retraction, tympanic membrane perforation, or calcification, ossicle erosion or other possible causes for hearing loss, determination of cholesteatoma, intratemporal complications such as petrositis, labyrinthitis, subperiosteal abscess, or labyrinthine fistula, intracranial complications such as brain abscess and meningitis, presence of fibrous tissue, tympanosclerosis, formation of new bone matter, ossicle erosion, and displacement and extension of cholesteatoma to sinuses.

MRI

Both CT and MRI are used in the evaluation of mastoiditis and its complications. MRI in mastoiditis plays a role in the detection of cholesteatoma, also when intracranial and some intratemporal complications are suspected. Specifically, MRI has shown superiority in assessing the severity of intracranial involvement and abscess border visualization.

Ultrasound

There are no ultrasound findings associated with mastoiditis.

Other Imaging Findings

There are no other diagnostic findings for mastoiditis.

Other Diagnostic Studies

Other mastoiditis imaging findings include otoscopic images of the tympanic membrane displaying middle ear effusion and infection. Also, tympanograms may be used for measuring pressure from fluid buildup in the middle ear.

Treatment

Medical Therapy

Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous antibiotics and myringotomy. Antibiotics for acute mastoiditis must cover the most common bacterial pathogens: Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus (including methicillin-resistant S. aureus). If there is a history of recurrent acute otitis media or recent antibiotic usage, the intravenous antibiotic also should cover Pseudomonas aeruginosa. Bacteria commonly covered include Streptococcus pneumonia, Group A streptococcus, and Staphylococcus aureus. The empiric antibiotics are ampicillin-sulbactam or ampicillin; add vancomycin for severe infection with adjacent complications or suspicion of MRSA. For chronic mastoiditis, bacteria commonly covered are Pseudomonas aeruginosa, Staphylococcus aureus and anaerobes. Antibiotics include piperacillin-tazobactam or piperacillin, and ofloxacin otic solution; add vancomycin for severe infection with adjacent complications or suspicion of MRSA.

Surgery

Different surgical procedures may be performed to treat mastoiditis. Myringotomy is surgical perforation of the tympanic membrane. It should be considered the primary treatment in all cases of infectious mastoiditis following otitis media, particularly when there is an unperforated tympanic membrane or inadequate drainage. Tympanocentesis should be performed in all mastoiditis patients to obtain middle ear fluid for culture and susceptibility testing. Myringotomy accompanied by the additional insertion of a tympanostomy tube is indicated in some cases, such as Eustachian tube dysfunction, suppurative complications requiring additional drainage, and when tympanic membrane must be repaired from Eustachian tube dysfunction. Definitive surgery is mastoidectomy, which is the surgical removal of the mastoid cortical bone and underlying air cells. Indications for mastoidectomy may include subperiosteal abscess such as postauricular fluctuance or mass, chronic suppurative otitis media or cholesteatoma, progression of postauricular swelling or fluctuance, fever, and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and myringotomy.

Primary Prevention

Preventing mastoiditis primarily involves preventing development of otitis media and nasopharyngitis. This is achieved by administration of the pneumococcal and influenza vaccines, frequently washing hands, and avoiding fluid transmission and respiratory droplets from nasopharyngitis patients. Preventing exposure to air pollution, as potential middle ear irritants such as secondhand smoke helps prevent otitis media, is also helpful in preventing mastoiditis. For infants, preventative measures include avoiding pacifiers, avoiding daycare enrollment, and breastfeeding until at least 6 months of age. A prophylactic regimen of antibiotics can prevent otitis media in at-risk infants and children.

Secondary Prevention

For mastoiditis following chronic or recurrent otitis media, preventing recurrence of the disease involves surgery, assuming the manifestation is not self-limited. Myringotomy with tympanostomy tube and mastoidectomy is the most common surgical preventative measure.

References

  1. Groth A, Enoksson F, Hultcrantz M, Stalfors J, Stenfeldt K, Hermansson A (2012). "Acute mastoiditis in children aged 0-16 years--a national study of 678 cases in Sweden comparing different age groups". Int. J. Pediatr. Otorhinolaryngol. 76 (10): 1494–500. doi:10.1016/j.ijporl.2012.07.002. PMID 22832239.

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