Mastoiditis

Understanding Mastoiditis

Mastoiditis is a serious bacterial infection of the mastoid process, the prominent bone located behind the ear. This condition typically develops as a complication of untreated or inadequately treated acute otitis media (middle ear infection). The mastoid bone contains air cells that connect to the middle ear, and when infection spreads from the middle ear to these air cells, it can cause inflammation and destruction of the bone structure.

Before the advent of antibiotics, mastoiditis was a leading cause of death in children. While now relatively rare in developed countries due to effective treatment of ear infections, it remains a serious condition that requires immediate medical attention. The infection can spread to nearby structures, including the brain, leading to life-threatening complications. Understanding the signs and symptoms of mastoiditis is crucial for early recognition and treatment, particularly in young children who are most susceptible to this condition.

Common Symptoms

Mastoiditis symptoms typically develop days to weeks after an ear infection and can progress rapidly. Early recognition is vital for preventing serious complications.

Key Clinical Features

• Postauricular swelling: Redness and swelling behind the affected ear
• Ear displacement: The ear may be pushed forward and downward
• Persistent otorrhea: Drainage from the ear that doesn't improve with treatment
• High fever: Often above 102°F (38.9°C)
• Tenderness: Pain when touching the mastoid area
• Irritability: Especially in young children
• Headache: Can indicate spreading infection
• Lethargy: Unusual tiredness or difficulty waking

Causes and Risk Factors

Mastoiditis develops when bacteria from a middle ear infection spread to the air cells of the mastoid bone. Understanding the causes and risk factors helps in prevention and early intervention.

Primary Causes

• Bacterial infection: Most commonly Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes
• Untreated otitis media: The most common preceding condition
• Resistant bacteria: Infections that don't respond to initial antibiotic treatment
• Chronic ear infections: Repeated infections weakening natural defenses
• Cholesteatoma: Abnormal skin growth in the middle ear

Risk Factors

• Age: Most common in children under 2 years old
• Immunocompromised state: Weakened immune system from disease or medications
• Anatomical variations: Abnormal mastoid air cell development
• Delayed treatment: Not seeking care for ear infections promptly
• Incomplete antibiotic courses: Not finishing prescribed medications
• Daycare attendance: Increased exposure to respiratory infections
• Seasonal factors: Higher incidence during cold and flu season

How Mastoiditis Develops

Understanding the progression from ear infection to mastoiditis helps explain why prompt treatment of ear infections is crucial.

Pathophysiology

• Initial infection: Bacteria enter the middle ear, usually through the Eustachian tube
• Inflammation: The middle ear becomes inflamed and fills with infected fluid
• Spread to mastoid: Infection extends through the aditus to mastoid air cells
• Bone destruction: Bacterial enzymes and inflammation break down bone tissue
• Abscess formation: Pus accumulates within the mastoid bone
• Potential spread: Infection can extend to surrounding structures

Timeline of Development

Mastoiditis typically develops 2-3 weeks after the onset of acute otitis media, though it can occur earlier in aggressive infections. The progression from simple inflammation to bone destruction can be rapid, emphasizing the importance of early recognition and treatment. In some cases, particularly with virulent organisms or immunocompromised patients, mastoiditis can develop within days of the initial ear infection.

Diagnosis

Diagnosing mastoiditis requires a combination of clinical examination, imaging studies, and laboratory tests. Early and accurate diagnosis is essential for appropriate treatment and prevention of complications.

Clinical Examination

• Otoscopic examination: Viewing the ear canal and tympanic membrane
• Physical examination: Checking for postauricular swelling and tenderness
• Neurological assessment: Evaluating for signs of complications
• Temperature monitoring: Documenting fever patterns

Imaging Studies

• CT scan: Gold standard for diagnosing mastoiditis and assessing bone destruction
• MRI: Better for evaluating soft tissue complications and intracranial extension
• X-rays: Less sensitive but may show cloudiness of mastoid air cells
• Ultrasound: Can detect subperiosteal abscesses

Laboratory Tests

• Complete blood count: Shows elevated white blood cells
• Inflammatory markers: Elevated ESR and CRP
• Blood cultures: To identify causative bacteria
• Ear fluid culture: If drainage is present

Treatment Options

Treatment of mastoiditis requires aggressive therapy to eliminate infection and prevent complications. The approach depends on the severity of infection and presence of complications.

Medical Management

• Intravenous antibiotics: High-dose broad-spectrum antibiotics initially
• Culture-directed therapy: Antibiotics adjusted based on culture results
• Duration: Typically 2-4 weeks of IV antibiotics followed by oral antibiotics
• Pain management: Analgesics for comfort
• Fever control: Antipyretics as needed

Surgical Interventions

• Myringotomy: Drainage of middle ear fluid
• Tympanostomy tubes: To maintain drainage and ventilation
• Simple mastoidectomy: Removal of infected mastoid air cells
• Radical mastoidectomy: More extensive surgery for severe cases
• Abscess drainage: For subperiosteal or intracranial abscesses

Treatment Decision Making

The choice between medical and surgical treatment depends on several factors including the extent of bone destruction, presence of complications, response to initial antibiotics, and overall clinical condition. Many cases require both medical and surgical management for optimal outcomes. Early surgical intervention may be necessary if there are signs of complications or failure to improve with antibiotics within 24-48 hours.

Complications

Without prompt treatment, mastoiditis can lead to serious, potentially life-threatening complications due to the proximity of the mastoid bone to vital structures.

Intracranial Complications

• Meningitis: Infection of the brain and spinal cord membranes
• Brain abscess: Collection of pus within brain tissue
• Epidural abscess: Infection between skull and dura mater
• Lateral sinus thrombosis: Blood clot in the brain's venous sinuses
• Subdural empyema: Pus collection beneath the dura mater

Extracranial Complications

• Facial nerve paralysis: Weakness or paralysis of facial muscles
• Labyrinthitis: Inner ear infection causing vertigo and hearing loss
• Petrositis: Infection spreading to the petrous apex
• Bezold's abscess: Infection tracking down the neck
• Subperiosteal abscess: Pus collection under the periosteum

Long-term Sequelae

• Chronic mastoiditis: Persistent infection requiring ongoing treatment
• Permanent hearing loss: From damage to middle or inner ear structures
• Chronic otorrhea: Persistent ear drainage
• Cholesteatoma formation: Abnormal skin growth in the ear

Prevention

Preventing mastoiditis primarily involves proper management of ear infections and reducing risk factors for otitis media.

Primary Prevention

• Vaccination: Pneumococcal and Haemophilus influenzae type b vaccines
• Breastfeeding: Provides antibodies that help prevent ear infections
• Avoid smoke exposure: Secondhand smoke increases infection risk
• Proper bottle feeding: Keep infant upright to prevent milk entering Eustachian tubes
• Hand hygiene: Regular handwashing to prevent respiratory infections
• Limit pacifier use: After 6 months of age

Secondary Prevention

• Prompt treatment: Seek medical care for ear pain or suspected ear infections
• Complete antibiotic courses: Finish all prescribed medications
• Follow-up care: Return visits to ensure infection resolution
• Monitor high-risk children: Those with recurrent ear infections
• Consider preventive tubes: For children with chronic ear problems

Recovery and Follow-up

Recovery from mastoiditis requires careful monitoring and extended treatment to ensure complete resolution of infection and prevent recurrence.

Hospital Care

• Initial monitoring: Close observation for response to treatment
• IV antibiotics: Usually required for 7-10 days minimum
• Pain management: Ensuring comfort during recovery
• Hearing assessment: Baseline and follow-up audiometry

Outpatient Management

• Oral antibiotics: Continued for 2-4 weeks after discharge
• Regular follow-up: Weekly visits initially, then as directed
• Imaging follow-up: May be needed to confirm resolution
• ENT specialist care: Ongoing management by ear, nose, and throat doctor

Long-term Monitoring

Children who have had mastoiditis require long-term follow-up to monitor for complications and ensure complete recovery. This includes regular hearing tests, assessment for chronic ear disease, and monitoring for signs of recurrence. Some children may need reconstructive surgery if there was significant bone destruction. The prognosis is generally excellent with appropriate treatment, but vigilance is necessary to detect and manage any long-term effects.

When to Seek Help

Recognizing when to seek medical attention for ear problems can prevent the development of mastoiditis and its complications.

Immediate Medical Attention

• Ear pain with swelling behind the ear
• Ear drainage that persists despite treatment
• High fever with ear symptoms
• Any neurological symptoms with ear infection
• Facial weakness or asymmetry
• Severe headache or neck stiffness

Routine Medical Care

• Ear pain lasting more than 2-3 days
• Recurrent ear infections
• Hearing concerns
• Persistent ear drainage
• Failed response to prescribed antibiotics

Remember that mastoiditis is a medical emergency requiring immediate treatment. Early recognition and aggressive management are key to preventing serious complications and ensuring the best possible outcome. If you suspect mastoiditis, do not delay in seeking emergency medical care.