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. 

Goldstein DP, Emans SJ, Laufer MR. The breast: examination and
lesions. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and
Adolescent Gynecology. 4th ed. Philadelphia, Pa: Lippincott-Raven;

Irwin CE Jr, Shafer MA, Moscicki AB. The adolescent patient: common
reproductive health problems: breast problems. In: Rudolph CD, Rudolph
AM, Hostetter MK, Lister G, Siegel NJ, eds. Rudolphís Pediatrics. 21st
ed. New York, NY: McGraw-Hill; 2003:246-248

Neinstein LS. Breast disorders. In: Adolescent Health Care: A
Practical Guide. 4th ed. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2002:1063-1084