Mastoiditis

🦻 Mastoiditis – Types, Pathophysiology, Clinical Features & Treatment

Mastoiditis is an important complication of chronic otitis media (CSOM) and can also follow acute otitis media.

📌 Types of Mastoiditis

1. Acute Mastoiditis
2. Masked / Latent Mastoiditis

🦠 Acute Mastoiditis

📖 Definition of Acute Mastoiditis

Inflammation of the mucosa lining the mastoid air cells with involvement of the bony walls of the mastoid system.

🔍 Etiology of Acute Mastoiditis

• Common in: Children

• Follows: Acute suppurative otitis media (ASOM) or CSOM

What are the predisposing factors of Acute Mastoiditis?

Which type of pneumatisation is mastoiditis common in?

What are the common microorganisms causing Acute Mastoiditis?

🧬 Pathophysiology of Acute Mastoiditis

1. Production of pus under tension

2. Hyperemic Decalcification

Describe the pathophysiology and steps of development of Acute Mastoiditis.

🩺 Clinical Features of Acute Mastoiditis

Symptoms

• Pain behind ear:

  • Persists, increases, or recurs after relief in ASOM

• Fever:

  • Persistent or recurrent despite antibiotics

• Ear discharge:

  • Profuse, more purulent
  • May stop if blocked, but other symptoms worsen

• Infants: Irritability, feeding problems

When should you suspect Acute mastoiditis in a case of ear discharge?

Signs

General

• Irritable, flushed, low-grade fever, ↑ pulse

Ear

• External auditory canal (EAC):

  • Mucopurulent / purulent discharge
  • Lighthouse sign
  • Sagging of posterior superior meatal wall – periostitis between canal wall & antrum

• Tympanic membrane (TM):

  • Small central perforation in pars tensa
  • Congested rest of Tympanic Membrane
  • May be intact, dull, opaque (inadequate antibiotics)

What is Lighthouse sign?

Mastoid

• Tenderness:

  • Elicit by pressing mastoid tip/posterior border/root of zygoma

• Swelling:

  • Edema → smooth "ironed-out" mastoid
  • Obliteration of retroauricular sulcus
  • Pinna pushed down & forward
  • Subperiosteal abscess / fistula possible

Hearing

• Conductive hearing loss (check with tuning fork if >7 yrs and pain-free)

🧪 Investigations of Acute Mastoiditis

• CBC: Polymorphonuclear leukocytosis

• ESR: Raised

• Ear swab: Culture & sensitivity

• X-ray mastoid / CT temporal bone

What Xray findings do you get in Acute Mastoiditis?

💊 Treatment of Acute Mastoiditis

1- Hospitalize immediately

Medical Treatment:

• Broad-spectrum antibiotics: Amoxicillin, Ampicillin, 3rd gen cephalosporins

• Add anaerobic coverage: Chloramphenicol / Metronidazole

• Analgesics as required

What are the indications of medical treatment of Acute Mastoiditis?

2- Myringotomy

What are the indications of Myringotomy in Acute Mastoiditis?

3- Surgical Treatment – Cortical Mastoidectomy

Aim:

• Exenterate mastoid air cells, remove pus pockets
• Continue antibiotics ≥ 5 days post-surgery

What are the indications of Surgical Treatment in Acute Mastoiditis?

🩻 Differential Diagnosis of Acute Mastoiditis

• Suppuration of mastoid lymph nodes
• Furunculosis of EAC
• Infected sebaceous cyst

How to differentiate between suppuration of lymph nodes and acute mastoiditis?

What are the differences between Acute Mastoiditis and Furunculosis?

⚠️ Complications of Acute Mastoiditis

• Subperiosteal abscess
• Labyrinthitis
• Facial nerve palsy
• Petrositis
• Septicemia
• Extradural abscess, subdural abscess
• Meningitis, brain abscess
• Lateral sinus thrombophlebitis
• Otitic hydrocephalus

😷 Masked (Latent) Mastoiditis

📖 Definition of Masked Mastoiditis

Slow destruction of mastoid air cells without acute signs seen in acute mastoiditis.

What is the cause of Masked Mastoiditis?

🧬 Pathology of Masked Mastoiditis

• Extensive destruction of mastoid air cells
• Granulation tissue & dark gelatinous material
• Possible erosion of tegmen tympani / sinus plate → extradural or perisinus abscess

🩺 Clinical Features of Masked Mastoiditis

• Mild pain behind ear
• Persistent conductive hearing loss
• No Tympanic Membrane perforation
• Slight mastoid tenderness
• No swelling, fever, or discharge

🧪 Investigations of Masked Mastoiditis

• X-ray mastoid: Clouded air cells, loss of septa
• Pure tone audiometry: Conductive hearing loss

💊 Treatment of Masked Mastoiditis

• Cortical mastoidectomy + full antibiotic course
• TM often returns to normal with improved hearing
• Prognosis better than acute mastoiditis