Mastoiditis

Aka: Mastoiditis, Acute Mastoiditis, Chronic Mastoiditis

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II. Epidemiology

  1. Rare since the regular use of Antibiotics to treat Acute Otitis Media

III. Pathophysiology

  1. Mastoid air spaces are continuous with the middle ear cavity
  2. Mastoiditis is a complication of Acute Otitis Media
    1. Extension of middle ear infection and inflammation
    2. Increased pressure destroys the mastoid septae dividing the air cells
    3. Abscess and destruction of mastoid bone

IV. Predisposing factors

  1. Acute Otitis Media extension (most common, esp. children)
  2. Chronic Otitis Media with secondary Cholesteatoma with obstruction of Ear Drainage
  3. Leukemia
  4. Mononucleosis
  5. Temporal Bone Sarcoma
  6. Kawasaki Disease

V. Causes: Bacteria associated with Acute Otitis Media

  1. Streptococcus Pneumoniae (22-57%)
  2. Streptococcus Pyogenes (16-31%)
  3. Staphylococcus Aureus (7-15%)
  4. Haemophilus Influenzae (4-13%, likely much lower Incidence post-Hib Vaccine)

VI. Causes: Bacteria associated with Chronic Otitis Media

  1. Staphylococcus Aureus (7% overall Mastoiditis cases)
  2. Pseudomonas Aeruginosa (4% overall Mastoiditis cases)
  3. Anaerobic Bacteria
  4. Other atypical causes of Chronic Mastoiditis
    1. Nocardia
    2. Actinomyces
    3. Mycobacterium tuberculosis

VII. Symptoms

  1. Severe Otalgia (81%)
  2. Fever (76%)
    1. Tmax may be >104 F
  3. Unresolved Otitis Media
  4. Hearing Loss
  5. Headache
  6. Pain at mastoid, occipital and parietal regions

VIII. Signs

  1. Swelling and tenderness over the mastoid process with local erythema, tenderness and fluctuance (85%)
    1. Postauricular
    2. Supraauricular
  2. Toxic appearance
  3. Inflamed and thickened TM (90% of cases)
  4. TM often perforated with Otorrhea

IX. Labs

  1. Complete Blood Count (CBC)
    1. Leukocytosis
  2. Acute Phase Reactants (ESR, CRP)
    1. May be useful in monitoring disease
  3. Cultures
    1. Blood Cultures (positive in only 14% of cases)
    2. Tympanocentesis for middle ear fluid (preferred) or Auditory canal culture

X. Imaging

  1. CT of Mastoid area (MRI if intracranial spread)
  2. Mastoiditis Findings
    1. Haziness or loss of mastoid air cells
    2. Periosteal thickening
    3. Subperiosteal abscess
  3. CNS Extension Findings
    1. Cerebritis
    2. Brain Abscess
    3. Sigmoid Sinus Thrombosis
  4. Diagnosis
  5. Mastoiditis is a clinical diagnosis
    1. Normal white count and normal inflammatory markers (e.g. CRP) does NOT exclude diagnosis
    2. Lack of mastoid air cell destruction on imaging does not exclude diagnosis

XI. Management: Acute Mastoiditis

  1. Admit for IV Antibiotics in most cases
  2. Consultations
    1. Otolaryngology Consultation (most cases)
    2. Neurosurgery Consultation Indications
      1. Brain Abscess (parenchymal or epidural)
      2. Sigmoid Sinus Thrombosis
  3. CNS Involvement (e.g. Brain Abscess, cerebritis, Sigmoid Sinus Thrombosis)
    1. Consult neurosurgery, infectious disease and otolaryngology
    2. Vancomycin AND
    3. Ceftazidime AND
    4. Metronidazole
  4. Complicated Mastoiditis (chronic infection, Osteomyelitis or mastoid abscess)
    1. Consult Otolaryngology (see surgical interventions below)
    2. Piperacillin-Tazobactam (Zosyn) OR Cefepime OR Ceftazidime OR Aztreonam AND
    3. Vancomycin (Linezolid may be used as an alternative)
      1. Child: 15 mg/kg IV every 6 hours
      2. Adult: 15-20 mg/kg IV every 8-12 hours
    4. Treat for 4-6 weeks, with Antibiotics based on cultures and sensitivity
  5. Uncomplicated Mastoiditis (children with first episode)
    1. Ampicillin-Sulbactam 50 mg/kg (up to 1.5 to 3 g) IV every 6 hours OR
    2. Ceftriaxone 50-100 mg/kg/day (up to 4 g/day) divided twice daily
    3. Treat for 7-10 days, with Antibiotics based on cultures and sensitivity
  6. Otolaryngology Surgical Management
    1. Myringotomy
      1. May be indicated if mastoid septal erosions (loss of air cells) on imaging
      2. Obtain specimen for culture
    2. Mastoidectomy
      1. Indicated in subperiosteal abscess
      2. Removes infected bone or mucosa

XII. Management: Chronic Mastoiditis

  1. Chronic Mastoiditis may be complicated by acute exacerbations
    1. See above for acute exacerbation Antibiotic and surgical management (complicated Mastoiditis protocol)
  2. External auditory canal measures
    1. Warm water self-irrigation of the external canal (if Tympanic Membrane intact)
    2. Topical Antibiotics (culture sensitivity directed if available)
      1. Ciprofloxacin or LevofloxacinEar Drops twice daily for 2 weeks
      2. Avoid Aminoglycoside drops (or systemic Antibiotics) due to Ototoxicity
  3. Otolaryngology Consultation
    1. Evaluate for Cholesteatoma
    2. Mastoidectomy indications
      1. Chronic drainage
      2. Osteomyelitis (e.g. Temporal Bone, petrous bone)
      3. CNS Spread of infection

XIII. Complications

  1. Osteomyelitis
  2. Bacterial Meningitis
  3. Temporal Lobe epidural or Subdural Abscess
  4. Septic thrombosis of lateral venous sinus

XIV. References

  1. (2025) Sanford Guide, accessed on IOS 3/4/2025
  2. Dumois (2020) Acute Mastoiditis Clinical Pathway, Johns Hopkins All Childrens Hospital
  3. Klein in Mandell (2000) Infectious Disease, p. 674
  4. Pfaff in Marx (2002) Rosen's Emergency Med., p. 932-3
  5. Lin (2010) Clin Pediatr 49(2):110-5 [PubMed]
  6. Loh (2018) J Laryngol 132(2): 96-104 +PMID:28879826 [PubMed]

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Related Studies

Ontology: Mastoiditis (C0024904)

Definition (MSHCZE) Zánět bradavkového výčnělku, obv. jako komplikace zánětu středního ucha (otitidy). Je nebezpečný dalším šířením infekce do mozku. Akutní m. vzniká při mezotitidě, někdy však se její příznaky mohou projevit až po odeznění nedostatečně léčeného zánětu. Jsou bolesti, celkové příznaky, výtok z ucha, zhoršení hypakuze, může být tinitus pulzujícího charakteru, lokálně bývá retroaurikulární prosáknutí, bolestivost až absces. Diagnózu doplňují i rtg změny. Terapie je operační – srov. (antro)mastoidektomie. Zvl. formami jsou tzv. okultní m. (může být u kojenců), nenápadná je rovněž mukózní m. (způsobená Staphylococcus mucosus). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) Inflammation of the honeycomb-like MASTOID BONE in the skull just behind the ear. It is usually a complication of OTITIS MEDIA.
Concepts Disease or Syndrome (T047)
MSH D008417
ICD9 383.9
ICD10 H70.9 , H70.90
SnomedCT 194309002, 155230007, 52404001
English Mastoiditides, Unspecified mastoiditis, Mastoiditis NOS, Mastoiditis, unspecified, Mastoiditis, mastoiditis (diagnosis), mastoiditis, Unspecified mastoiditis, unspecified ear, Mastoiditis [Disease/Finding], Mastoiditis NOS (disorder), Mastoiditis (disorder), Mastoiditis, NOS
Dutch mastoïditis NAO, niet-gespecificeerde mastoïditis, Mastoïditis, niet gespecificeerd, mastoïditis, Mastoiditis
French Mastoïdite SAI, Mastoïdite non précisée, Mastoïdite
German Mastoiditis NNB, unspezifische Mastoiditis, Mastoiditis, nicht naeher bezeichnet, Mastoiditis
Italian Mastoidite non specificata, Mastoidite NAS, Mastoidite
Portuguese Mastoidite NE, Mastoidite
Spanish Mastoiditis no especificada, Mastoiditis NEOM, mastoiditis, SAI, mastoiditis, SAI (trastorno), mastoiditis (trastorno), mastoiditis, Mastoiditis
Japanese 乳様突起炎, 詳細不明の乳様突起炎, 乳様突起炎ＮＯＳ, ﾆｭｳﾖｳﾄｯｷｴﾝNOS, ﾆｭｳﾖｳﾄｯｷｴﾝ, ｼｮｳｻｲﾌﾒｲﾉﾆｭｳﾖｳﾄｯｷｴﾝ
Swedish Mastoidit
Czech mastoiditida, Blíže neurčená mastoiditida, Mastoiditida, Mastoiditida NOS
Finnish Mastoidiitti
Russian MASTOIDIT, МАСТОИДИТ
Korean 상세불명의 꼭지염
Croatian MASTOIDITIS
Polish Zapalenie wyrostka sutkowatego
Hungarian nem meghatározott mastoiditis, mastoiditis, mastoiditis k.m.n.
Norwegian Mastoiditt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Chronic mastoiditis (C0155447)

Concepts Disease or Syndrome (T047)
ICD9 383.1
ICD10 H70.1 , H70.10
SnomedCT 194299006, 155232004, 80645004
English Chronic mastoiditis NOS, chronic mastoiditis (diagnosis), chronic mastoiditis, Chronic mastoiditis, unspecified ear, Chronic mastoiditis NOS (disorder), Chronic mastoiditis, Chronic mastoiditis (disorder), chronic; mastoiditis, mastoiditis; chronic
Dutch chronische mastoïditis, chronisch; mastoïditis, mastoïditis; chronisch, Chronische mastoïditis
French Mastoïdite chronique
German chronische Mastoiditis, Chronische Mastoiditis
Italian Mastoidite cronica
Portuguese Mastoidite crónica
Spanish Mastoiditis crónica, mastoiditis crónica, SAI, mastoiditis crónica, SAI (trastorno), mastoiditis crónica (trastorno), mastoiditis crónica
Japanese 慢性乳様突起炎, ﾏﾝｾｲﾆｭｳﾖｳﾄｯｷｴﾝ
Czech Chronická mastoiditida
Korean 만성꼭지염
Hungarian chronicus mastoiditis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute mastoiditis (C0701825)

Concepts Disease or Syndrome (T047)
ICD9 383.0
ICD10 H70.0
SnomedCT 267670009, 155231006, 194297008, 17506007, 194293007, 386034005
English Acute mastoiditis NOS, acute mastoiditis (diagnosis), acute mastoiditis, Acute mastoiditis NOS (disorder), Acute mastoiditis (disorder), mastoiditis; acute, acute; mastoiditis, Acute mastoiditis, NOS, Acute mastoiditis [Ambiguous], Acute mastoiditis
Dutch acute mastoïditis, acuut; mastoïditis, mastoïditis; acuut, Acute mastoïditis
French Mastoïdite aiguë
German akute Mastoiditis, Akute Mastoiditis
Italian Mastoidite acuta
Portuguese Mastoidite aguda
Spanish Mastoiditis aguda, mastoiditis aguda, SAI (trastorno), mastoiditis aguda, SAI, mastoiditis aguda (trastorno), mastoiditis aguda
Japanese 急性乳様突起炎, ｷｭｳｾｲﾆｭｳﾖｳﾄｯｷｴﾝ
Czech Akutní mastoiditida
Korean 급성 꼭지염
Hungarian heveny mastoiditis
Derived from the NIH UMLS (Unified Medical Language System)

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