Mastoiditis, Acute
A 5-year-old boy presents
with fever and right ear pain of 48 hours'
duration. Physical examination reveals erythema and bulging of the
right tympanic membrane as well as postauricular erythema, edema, and
fluctuance.
Acute mastoiditis is inflammation or
infection of the mastoid air
cells or bone. This is a common sequela of otitis media because the
mastoid air cells are a direct extension
of the middle ear. Acute
mastoiditis presents with fever, ear pain, and signs of acute otitis
media. Secondary inflammation of the
mastoid may present with
erythema, edema, and tenderness over the mastoid bone as well as
protrusion of the pinna. Simple acute mastoiditis may progress to
coalescent mastoiditis in which
destructive osteitis causes loss of
visible bony septa on mastoid radiographs. Mastoiditis may result in
secondary sub-periosteal or intracranial
abscesses. A subperiosteal
abscess presents with fluctuance over the mastoid bone as well as
lateral protrusion of the ear, as described for the boy in the
vignette. Acute mastoiditis, very much like acute otitis media, is
caused most commonly by Streptococcus
pneumoniae and Haemophilus
influenzae. Moraxella sp is a much less common cause.
Computed tomography of the temporal bone
is the diagnostic procedure
of choice if bony erosion or associated abscess is suspected.
Intracranial abscess may be diagnosed by magnetic resonance imaging,
but this study is less useful for imaging the temporal bone.
Acute mastoiditis is treated by
myringotomy or tube insertion for
drainage of the middle ear. Specimens should be sent for Gram stain
and routine culture and sensitivity. When mastoiditis is complicated
by osteitis or abscess, as for the patient in the vignette, the
abscess should be drained and a simple mastoidectomy performed.
Empiric treatment with parenteral
antibiotics is recommended pending
culture results. Good antibiotic choices
include a broad-spectrum
cephalosporin (eg, ceftriaxone) intravenously or ampicillin-sulbactam. Vancomycin usually is not recommended,
and amoxicillin alone generally
is inadequate. Signs and symptoms of infection typically resolve
rapidly.
Although tube insertion often is recommended as an adjunct to
myringotomy and abscess drainage, tube insertion without antibiotics
is not recommended.
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