History

Fact Explanation
Introduction to the disease Acute mastoiditis is a well known and serious complication of acute otitis media. Disease commonly seen among pediatric population. However incidence of acute mastoiditis has been decreased recently due to revolution of antibiotic therapy.[1]. In the pathological process of the disease, first there is an obstruction and sequestration of infection at the additus, antrum and the smaller air cell tracts. After that temporal or mastoid bone remodeling , resorption and decalcification of the bones may result.[5].
Post aural swelling Post-aural swelling with inflammatory signs such as redness, increased temperature is a classic presentation of acute mastoiditis.[1]. However edema in soft parts behind the auricle is usually a late symptom.[2].
Otorrhea Disease may cause weakened tympanic membrane which may rupture at some stage of disease. This rupture may leads to develop acute otorrhea.[1]. This discharge may purulent and creamy in consistency.[2].
Pain Some patients may develop pain in the mastoid region of the ear. It is not a constant feature.[2].
Fever Fever is a non specific symptom which can be resulted due to ongoing inflammation.[2].
Tenderness Some patients may present with ear tenderness which is commonly developed by the application of digital pressure on the mastoid process.[2].
Subperiosteal abscess Progression of the inflammatory process will lead to this condition. when the suppuration escapes through the thinned out mastoid cortex and is entrapped by the periosteum as well as skin over the temporal bone and mastoid tip ,it may cause development of subperiosteal abscess which is pointing superior to or directly over the mastoid tip.[1].
Sigmoid sinus thrombosis A recognized complication of acute mastoiditis due to extension of inflammatory process beyond the tympanomastoid system.[1].
Suppurative labyrinthitis and meningitis Both are significant and life-threatening complications of disease which occurs due to spreading beyond the tympanomastoid system such as invasion of internal structures of the brain [1].
Epidural / subdural abscess, brain abscess, Those are serious life threatening complications of acute mastoiditis which may result due to invasion of internal structures of the brain due to progression of disease.[1].
Otitic hydrocephalus Another complication that occurs due to extension of inflammatory process beyond the tympanomastoid system.[1].
Facial paralysis Seen in some affected individuals due to involvement of facial nerve.[1].
Hearing loss Infection spreading to surrounding structures that contribute to hearing may cause conductive type hearing loss.[3].
Bezold's abscess, It is a rare complication of acute mastoiditis.[1]. It is a collection of abscess deep to sternocleidomastoid muscle.[4].
History of recurrent otitis media Disease found to be associated with recurrent otitis media. Usually the mastoid air cells are in continuity with the middle ear space through the aditus and antrum . In AOM they are liable to get blocked by inflammatory reaction of the lining mucosa. This will ultimatly causes infected non draining mastoid cavity which may leads to develop acute mastoititis.[1].
References
  1. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  2. MATHEWSON GH. THE DIAGNOSIS AND TREATMENT OF ACUTE MASTOIDITIS Can Med Assoc J [online] 1913 Aug, 3(8):672-678 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579830
  3. PALUDETTI G, CONTI G, DI NARDO W, DE CORSO E, ROLESI R, PICCIOTTI PM, FETONI AR. Infant hearing loss: from diagnosis to therapy Official Report of XXI Conference of Italian Society of Pediatric Otorhinolaryngology Acta Otorhinolaryngol Ital [online] 2012 Dec, 32(6):347-370 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552543
  4. LAZIM NORHAFIZA MAT. An Extensive Cholesteatoma with Bezold’s Abscess. IJCM [online] 2011 December, 02(03):292-294 [viewed 20 October 2014] Available from: doi:10.4236/ijcm.2011.23049
  5. LOWRY T, RAJA L, VERGHESE A. Mastoiditis, lymphoma, and AIDS. West J Med [online] 1998 Sep, 169(3):173-175 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305205

Examination

Fact Explanation
Post aural swelling Commonly detected sign on clinical examination. It can be fluctuant or non fluctuant.[1].
Protrusion of the auricle Protrusion of the auricle and retroauricular cellulitis are classic features and essential for diagnosis. Antero-inferior displacement of the auricle can be noticed in affected patients due to underline swelling.[1].
Post auricular erythema Inflammatory features such as post-auricular erythema / redness can be detected in examination.[1].
Tenderness Application of digital pressure on the mastoid process will produce tenderness. The tenderness may be elicited in all parts of the mastoid bone in some patients where the others it is limited to certain areas only.Over the site of the antrum which is behind the external meatus,tip of the mastoid process as well as at the spot where the mastoid emissary vein perforates the bone are the places which can develop tenderness. An osteitis, or a periostitis of the underlying bone can be the reason to develop tenderness. [2].
Prolapse of the postero-superior wall of the meatus Not commonly seen.Extension of the inflammatory process in the underlying bone in to the soft parts will cause this manifestation. If present it is an indication for operation.[2].
Ear discharge Otolaryngological examination will show purulent creamy ear discharge with perforation of tymphanic membrane.[1],[2].
Bony erosion Erosion of bones can be seen in temporal as well as mastoid bones. Later there will be bone remodeling bone resorption as well as decalcification.[1],[4].
Facial nerve palsy Cranial nerve examination will sometimes show features of facial nerve palsy due to involvement of facial nerve.[1].
Hearing loss Cranial nerve examination of some affected individuals may reveal conductive type of hearing loss.[3].
References
  1. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  2. MATHEWSON GH. THE DIAGNOSIS AND TREATMENT OF ACUTE MASTOIDITIS Can Med Assoc J [online] 1913 Aug, 3(8):672-678 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579830
  3. PALUDETTI G, CONTI G, DI NARDO W, DE CORSO E, ROLESI R, PICCIOTTI PM, FETONI AR. Infant hearing loss: from diagnosis to therapy Official Report of XXI Conference of Italian Society of Pediatric Otorhinolaryngology Acta Otorhinolaryngol Ital [online] 2012 Dec, 32(6):347-370 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552543
  4. LOWRY T, RAJA L, VERGHESE A. Mastoiditis, lymphoma, and AIDS. West J Med [online] 1998 Sep, 169(3):173-175 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305205

Differential Diagnoses

Fact Explanation
Suppurative otitis media It causes either recurrent or persistent discharge called otorrhoea, through a perforation in the tympanic membrane. It is a well known cause of hearing impairment,disability, as well as poor scholastic performance.Fatal intracranial infections and acute mastoiditis may result in serious conditions. Disease may leads to mucosal polyps,thickening of the middle ear mucosa as well as cholesteatoma.[1].
Acute otitis externa It is also called as "swimmer’s ear". Commonly seen among children, adolescents as well as adults. It is a diffuse inflammation of the external ear canal. Affected individuals may present with otalgia , itching and fullness. Some may present with hearing loss and ear canal pain when chewing. Many of them are present with ear discharge. Inflammatory signs as well as tenderness of the tragus and pinna can be seen in diffuse disease.[2].
Mumps It is an acute, self-limiting viral infection. It can cause nonsuppurative swelling and tenderness of the salivary gland. Usually the symptoms of mumps confined to infectious parotitis. Sever complications include orchitis, pancreatitis, as well as meningitis.[3].
Traumatic opacified middle ear Blunt head injury may leads to trauma to the temporal bone. Patient with basal skull fracture may present with battle sign, raccoon eyes, or either with hemotympanum. Some of them may complain hearing loss and dizziness. Delayed presentations include cerebrospinal fluid otorrhea, symptoms related to cranial nerve VII dysfunction as well as hearing loss. Imaging studies in the tympanic cavity may show opacity due to the presence of blood or CSF.[4].
Middle ear adenoma They are rare, grossly vascular tumors. They are well circumscribed despite having no capsule.Conductive hearing loss is the common presenting symptom. Other features include otalgia,aural fullness as well as facial nerve palsy.[5].
Furuncle of external auditory canal Intense earache is a cardinal symptom. Any movement of the mandible, such as mastication or yawning or pressure over the tragus may cause aggravation of pain. A small reddened elevation can be seen in inspection of the auditory canal.[6].
Posterior auricular lymphadenopathy Posterior auricular lymphadenopathy can mimic acute mastoiditis. Posterior auricular lymph nodes are belongs to cervical lymph nodes. They appear in case of underline disease such as malignancy. Enlargement of posterior auricular lymph nodes specially seen in rubella.[7].
References
  1. ACUIN J. Chronic suppurative otitis media Clin Evid (Online) [online] :0507 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943814
  2. HUI CP, CANADIAN PAEDIATRIC SOCIETY, INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE. Acute otitis externa Paediatr Child Health [online] 2013 Feb, 18(2):96-98 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3567906
  3. TAE BS, HAM BK, KIM JH, PARK JY, BAE JH. Clinical Features of Mumps Orchitis in Vaccinated Postpubertal Males: A Single-Center Series of 62 Patients Korean J Urol [online] 2012 Dec, 53(12):865-869 [viewed 20 October 2014] Available from: doi:10.4111/kju.2012.53.12.865
  4. TROJANOWSKA A, DROP A, TROJANOWSKI P, ROSIńSKA-BOGUSIEWICZ K, KLATKA J, BOBEK-BILLEWICZ B. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms Insights Imaging [online] , 3(1):33-48 [viewed 20 October 2014] Available from: doi:10.1007/s13244-011-0126-z
  5. ISENRING D, PEZIER TF, VRUGT B, HUBER AM. Middle Ear Adenoma: Case Report and Discussion Case Rep Otolaryngol [online] 2014:342125 [viewed 20 October 2014] Available from: doi:10.1155/2014/342125
  6. GIDOLL SH. Furunculosis of External Auditory Canal Cal West Med [online] 1935 May, 42(5):378-380 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1752165
  7. KARPF M, WALKER HK, HALL WD, HURST JW. Lymphadenopathy [online] 1990 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21250099

Investigations - for Diagnosis

Fact Explanation
CT scan Diagnosis is mainly clinical with the help of imaging, such as CT and MRI.Temporal bone CT will show soft tissue density in the middle ear and mastoid cavity as well as erosion and defect of cortical bone of the mastoid cavity. It may sometime reveal contrastenhanced subperiosteal shadows.[1].CT is often used in suspected cases of mastoiditis. Studies suggest that CT is able to distinguish between coalescent and non-coalescent mastoiditis with a high sensitivity as well as specificity. And also it is usefull to certain other disease mentioned under differential diagnosis.[2],[3].
MRI MRI is useful to determine intracranial complications.[1]. And also MRI has a good accuracy for diagnosis of mastoiditis and concurrent subperiosteal abscesses. T2-weighted (T2W) images, DWI as well as contrast-enhanced MRI are the types of MRI that can be used. However resent studies suggest that MRI has less accuracy to detect acute mastoiditis.Longer scan times, more limited availability, and also the need of general anesthesia are the disadvantages of MRI compared to CT in pediatric population.MRI is also useful to exclude differential diagnosis which is mentioned under DD.[2],[3].
Skull X ray Useful to exclude underline fractures such as fractures in base of the skull.[4].
Bacterial culture Fluid can be extracted from the middle ear when there is a discharge. Then Gram staining and culture is carried out.Streptococcus pneumoniae and Streptococcus pyogenes are the commonly identified organisms. Culture may also useful prior to start antibiotic to select appropriate antibiotic type.[3],[1].
Lumbar puncture Can be performed in case of suspected intracranial spread, specially in case of meningitis.[3].
Full blood count Carried out to detect features of ongoing bacterial infection such as leukocytosis.[3].
ESR Elevated ESR level can be seen due to ongoing inflammation.[3].
Blood culture Can perform when systemic inflammatory features such as fever is present.[1],[3].
Audiograms Carried out for hearing assessment because some patients are presented with conductive type hearing loss.[5].
References
  1. KIM SR, CHOO OS, PARK HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess Korean J Audiol [online] 2013 Sep, 17(2):97-100 [viewed 20 October 2014] Available from: doi:10.7874/kja.2013.17.2.97
  2. PLATZEK I, KITZLER HH, GUDZIOL V, LANIADO M, HAHN G. Magnetic resonance imaging in acute mastoiditis Acta Radiol Short Rep [online] , 3(2):2047981614523415 [viewed 20 October 2014] Available from: doi:10.1177/2047981614523415
  3. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  4. TROJANOWSKA AGNIESZKA, DROP ANDRZEJ, TROJANOWSKI PIOTR, ROSIńSKA-BOGUSIEWICZ KATARZYNA, KLATKA JANUSZ, BOBEK-BILLEWICZ BARBARA. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms. Insights Imaging [online] December, 3(1):33-48 [viewed 20 October 2014] Available from: doi:10.1007/s13244-011-0126-z
  5. PALUDETTI G, CONTI G, DI NARDO W, DE CORSO E, ROLESI R, PICCIOTTI PM, FETONI AR. Infant hearing loss: from diagnosis to therapy Official Report of XXI Conference of Italian Society of Pediatric Otorhinolaryngology Acta Otorhinolaryngol Ital [online] 2012 Dec, 32(6):347-370 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552543

Investigations - Fitness for Management

Fact Explanation
FBC Can be perform not only to detect infection but also to assess fitness prior to a surgery. Specially to assess Hb levels.[1],[2]
References
  1. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  2. KIM SR, CHOO OS, PARK HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess Korean J Audiol [online] 2013 Sep, 17(2):97-100 [viewed 20 October 2014] Available from: doi:10.7874/kja.2013.17.2.97

Investigations - Followup

Fact Explanation
Audiometric assessment Should be carried out as a followup investigation to assess hearing impairment.[1],[2].
References
  1. KIM SR, CHOO OS, PARK HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess Korean J Audiol [online] 2013 Sep, 17(2):97-100 [viewed 22 October 2014] Available from: doi:10.7874/kja.2013.17.2.97
  2. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 22 October 2014] Available from: doi:10.1186/1472-6815-10-1

Management - General Measures

Fact Explanation
Patient education Educate the patient n regarding the disease as well as their family specially in case of pediatric patient. Educate them well about possible life threatening complications that will result if left untreated. And also discuss about the available treatment options and take informed written consent if patient is undergoing for a surgery.[1].
Intravenous antibiotics Conservative treatments also can give successful outcome.Broad spectrum Intravenous antibiotics such as Ceftriaxone which can be acts against Streptococcus can be tried for one to two days followed by oral about one to two weeks if the condition is not more sever enough to go for an immediate surgery. Antibiotics can be changed depend on the culture results. Resistant cases can be treat with an appropriate surgery.[1],[2].
Pain killers Paracetamol like simple pain killers can be used to pain control. It can be change according to the severity of pain.[2].
References
  1. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  2. KIM SR, CHOO OS, PARK HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess Korean J Audiol [online] 2013 Sep, 17(2):97-100 [viewed 20 October 2014] Available from: doi:10.7874/kja.2013.17.2.97

Management - Specific Treatments

Fact Explanation
Incisional & Drainage (I&D) Incisional and drainage is one of the available surgical method for acute mastoidits. Combination of I & D, ventilation, and intravenous antibiotics has shown successful outcome.[1].
Ventilation tube insertion Another available treatment option.These less invasive treatment modalities can be consider prior to mastoidectomy to minimize anesthetic risks as well as possible adverse effects of the ventilation system in the temporal bone which may result in mastoidectomy. The commonly found indications for simple mastoidectomy and ventilation tube insertion are patient who are presented with protruded mastoid abscess and the age of them over 30 months old with weight more than 15 kg, The presence of intracranial co-morbidities as well as in patients who diagnose to have cholesteatoma.[1].
Myringotomy Early consideration and performance of myringotomy is another treatment option. This surgical method is less invasive than the mastoidectomy.[1],[2].
Mastoidectomy If I & D, ventilation,myringotomy and intravenous antibiotics treatments were not responded can be go for a invasive surgical option such as mastoidectomy. It is usually performed 48 to 72 hours of conservative treatment. It performed under GA.Simple mastoidectomy and ventilation tube insertion usually performed in case of associated complications such as mastoid abscess, in the presence of intracranial comorbidities,failure of 2 week antibiotic treatment in patients with granuloma and suppurative otorrhea as well as patients who are diagnosed to have cholesteatoma.[1].Surgery carries high risk of complications such as permanent hearing loss and damage to surrounding structures.[3],[2].
References
  1. KIM SR, CHOO OS, PARK HY. Two Cases of Acute Mastoiditis with Subperiosteal Abscess Korean J Audiol [online] 2013 Sep, 17(2):97-100 [viewed 20 October 2014] Available from: doi:10.7874/kja.2013.17.2.97
  2. ABDEL-AZIZ MOSAAD, EL-HOSHY HASSAN. Acute mastoiditis: A one year study in the pediatric hospital of Cairo university. Array [online] 2010 December [viewed 20 October 2014] Available from: doi:10.1186/1472-6815-10-1
  3. MATHEWSON GH. THE DIAGNOSIS AND TREATMENT OF ACUTE MASTOIDITIS Can Med Assoc J [online] 1913 Aug, 3(8):672-678 [viewed 20 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579830