Rosen & Barkin's 5-Minute Emergency Medicine Consult (439 page)

• Organisms in acute mastoiditis are similar to those in acute otitis media, but differ in frequency:
  
  • Streptococcus pneumoniae
    
  • Group A streptococcus
    
  • Staphylococcus aureus
    
  • Haemophilus influenzae
    
• Gram-negative enteric bacteria most common with chronic mastoiditis:
  
  • Pseudomonas aeruginosa
    
  • Escherichia coli
    
  • Proteus mirabilis
    
  • Bacteroides
    species
    
• Other less common causes:
  
  • Mycobacterium tuberculosis
    
  • Aspergillus
    species in immunocompromised states
    

• More frequently seen in the pediatric population due to strong association with otitis media
  
• S. pneumoniae
  is the most common cause in children
  

DIAGNOSIS

• Ear pain
  
• Otorrhea
  
• Mild to severe hearing loss
  
• Fever
  
• Headache
  
• History of irritability in a child
  
• History of recurrent otitis media
  

• Tenderness, edema, and erythema over the mastoid
  
• Lateral and inferior displacement of the auricle
  
• Loss of the postauricular crease
  
• Swelling of the posterior and superior ear canal wall
  
• Tympanic membrane abnormalities consistent with severe otitis media
  
• Purulent fluid drainage from the auditory canal
  
• Bulging tympanic membrane
  

Mastoiditis is a clinical diagnosis

• CBC:
  
  • Leukocytosis
    
• Cultures of drainage important owing to diversity of organisms:
  
  • If spontaneous drainage present or after surgical drainage
    
• Blood cultures if patient appears toxic
  

• Mastoid plain radiographs:
  
  • Early stage of disease may show hazy or cloudy but intact mastoid
    
  • May reveal opacification or coalescence of the mastoid air cells or coalescence as disease progresses
    
  • Unreliable due to low sensitivity
    
• CT scan:
  
  • More useful, especially if abscess formation present
    
  • Can determine presence and extent of destruction of trabeculae as well as evaluate for the complications of mastoiditis
    
• MRI:
  
  • If intracranial involvement suspected but not confirmed by CT
    

• Conservative use of CT in children may be warranted
  
• The diagnosis can often be made on clinical grounds and avoids radiation exposure
  

Lumbar puncture:

• Cerebrospinal fluid evaluation for signs of meningitis
  

• Otitis media
  
• Cellulitis
  
• External otitis media
  
• Scalp infection with inflammation of posterior auricular nodes
  
• Rubella: Posterior auricular node enlargement
  
• Trauma to pinna or postauricular area
  
• Meningitis
  

TREATMENT

• ABCs
  
• Airway management for signs of airway compromise
  
• 0.9% NS IV fluid bolus for hypotension/volume depletion
  

• Initiate IV antibiotics
  
• Otolaryngologist consult for surgical drainage:
  
  • Drainage is the definitive therapy for acute or coalescent mastoiditis
    
  • Emergent drainage if the patient appears toxic
    
  • Types of surgical procedures:
    
    • Myringotomy drainage and tympanostomy tube placement
      
    • Mastoidectomy and drainage for severe extension (needed in ∼50% of cases)
      

• Initiate IV antibiotics:
  
  • Given increasing proportion of
    S. aureus
    as causative organism, consider including antistaphylococcal agent before culture results
    
  • Parenteral antibiotics can be switched to PO after patient afebrile for 36–48 hr
    
  • Consider antipseudomonal coverage when appropriate
    
• Administer pain medications:
  
  • NSAIDs
    
  • PO or parenteral narcotics
    

• Ceftriaxone: 1–2 g (peds: 50–75 mg/kg/24 h) IV q12–24 h
  
• Cefotaxime: 1–2 g (peds: 50–180 mg/kg/24 h) IV q4–6h
  

• Ampicillin/sulbactam: 1.5–3 g IV q6h
  
• Chloramphenicol: 50–100 mg/kg/24 h IV or PO q6h
  
• Clindamycin: 600–2,700 mg/d IV div. q6–12h or 150–450 mg PO q6–8h (peds: 20–40 mg/kg/d IM/IV div. q6–8h or 10–25 mg/kg/d PO div. q6–8h)
  
• Ticarcillin/clavulanate: 3.1 g IV q4–6h
  
• Piperacillin/tazobactam: 3.375 g IV q6h
  
• Vancomycin: 1 g q8h (peds 40 mg/kg/24 h) IV q6–8h
  

FOLLOW-UP

• Clinical suspicion of acute or coalescent mastoiditis
  
• Subperiosteal abscess
  
• Toxic appearing
  

Patients with acute or coalescent mastoiditis should not be discharged

• Otolaryngologist consult for possible surgical drainage
  
• Audiography should be performed after resolution of mastoiditis to assess hearing loss
  

Patients should follow up with otolaryngologist after discharge, if not admitted

• Bezold abscess:
  
  • Extension of infection to soft tissue below pinna or behind the sternocleidomastoid muscle of neck after erosion through the mastoid tip
    
• Petrositis:
  
  • Spread of the infection to the petrous air cells
    
• Osteomyelitis of the calvarium
  
• Intracranial complications:
  
  • Subperiosteal abscess
    
  • Subdural empyema:
    
    • Extension of infection to CNS with empyema around the tentorium
      
  • Sinus thromboses
    

Even with conservative management of otitis media, a 10-yr analysis did not show a significant increase in cases of acute mastoiditis.

• It is important to maintain a high index of suspicion for mastoiditis in setting of persistent or untreated acute otitis media.
  
• Failure to recognize meningitis or intracranial involvement, which require more aggressive management, is a pitfall
  
• Drainage is the definitive therapy
  

• Anderson KJ. Mastoiditis.
  Pediatr Rev
  . 2009;30:233–234.
  
• Anthonsen K, Høstmark K, Hansen S, et al. Acute mastoiditis in children. A 10-year retrospective and validated multicenter study.
  Pediatr Infect Dis J
  . 2013;32:436–440.
  
• Devan PP. Mastoiditis. Emergency medicine. Emedicine. Available at
  http://emedicine.medscape.com/article/784176-overview
  .
  
• Liao YJ, Liu TC. Images in clinical medicine.
  Mastoiditis. N Engl J Med.
  2013;368:2014.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. St. Louis, MO: Mosby; 2009.
  
• Tamir S, Schwartz Y, Peleg U, et al. Acute mastoiditis in children: Is computed tomography always necessary?
  Ann Otol Rhinol Laryngol
  . 2009;118:565–569.
  
• Tamir S, Schwartz Y, Peleg U, et al. Shifting trends: Mastoiditis from a surgical to a medical disease.
  Am J Otolaryngol
  . 2010;31:467–471.
  

CODES

• 383.00 Acute mastoiditis without complications
  
• 383.01 Subperiosteal abscess of mastoid
  
• 383.9 Unspecified mastoiditis
  

BASICS