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Mastoiditis - Causes, Symptoms and Treatment

Definition:

Mastoiditis is a bacterial infection and inflammation of the air cells of the mastoid antrum. Although the prognosis is good with early treatment, possible complications include meningitis, facial paralysis, brain abscess, and suppurative labyrinthitis.

Causes of Mastoiditis

Bacteria that cause mastoiditis include pneumococci, Haemophilus influenzae, Moraxella catarrhalis, beta-hemolytic streptococci, staphylococci, and gram­negative bacteria, the same microbes that cause acute otitis media. Mastoiditis is usually a complication of chronic otitis media; less frequently, it develops after acute otitis media. An accumulation of pus under pressure in the middle ear cavity results in necrosis of adjacent tissue and extension of the infection into the mastoid cells. Chronic systemic diseases or immunosuppression may also lead to mastoiditis. While pneumococcal mastoiditis is usually not symptomatic, it can be very destructive. Coalescence of the mastoid air cells may precede rupture of the tympanic membrane. Streptococcal mastoiditis is generally preceded by early rupture of the tympanic membrane and copious otorrhea.

Signs and Symptoms of Mastoiditis

Symptoms of mastoiditis are usually noticed 2 weeks or more after untreated acute otitis media, due to destruction of one of the mastoid processes. Primary clinical features include persistent and throbbing pain and tenderness in the area of the mastoid process, low-grade fever, headache, and a thick, purulent discharge that gradually becomes more profuse, possibly leading to otitis externa. Postauricular erythema and edema may push the auricle out from the head; pressure within the edematous mastoid antrum may produce swelling and obstruction of the external ear canal, causing conductive hearing loss.

Diagnosis for Mastoiditis

X-rays of the mastoid area reveal hazy mastoid air cells; the bony walls between the cells appear decalcified due to purulent fluid, swollen mucous membranes, and granulation tissue in the air cells. Audiometric testing may reveal a conductive hearing loss. Physical examination shows a dull, thickened, and edematous tympanic membrane, if the membrane isn't concealed by obstruction. During examination, the external ear canal is cleaned; persistent oozing into the canal indicates perforation of the tympanic membrane. Differential diagnoses include serous otitis media, acute otitis media, petrous apicitis, and sigmoid sinus thrombosis.

Treatment for Mastoiditis

Treatment of mastoiditis consists of intense parenteral antibiotic therapy. I.V. penicillin is the initial drug of choice for at least a 2-week duration. If bone damage is minimal, myringotomy drains purulent fluid and provides a specimen of discharge for culture and sensitivity testing. Recurrent or persistent infection or signs of intracranial complications necessitate simple mastoidectomy. This procedure involves removal of the diseased bone and cleaning of the affected area, after which a draill is inserted.

A chronically inflamed mastoid requires radical mastoidectomy (excision of the posterior wall of the ear canal, remnants of the tympanic membrane, and the malleus and incus, although these bones are usually destroyed by infection before surgery). The stapes and facial nerve remain intact. Radical mastoidectomy, which is seldom necessary because of antibiotic therapy, does not drastically affect the patient's hearing because significant hearing loss precedes surgery. With either surgical procedure, the patient continues oral antibiotic therapy for several weeks after surgery and hospital discharge.

Special Considerations and Prevention Tips for Mastoiditis

  • After radical mastoidectomy, the wound is packed with petroleum gauze or gauze treated with an antibiotic ointment. Give pain medication before the packing is removed, on the fourth or fifth postoperative day.
  • Because of stimulation to the inner ear during surgery, the patient may feel dizzy and nauseated for several days afterward. Keep the side rails up, and assist the patient with ambulation. Also, give antiemetics as needed.
  • Before discharge, teach the patient and family how to change and care for the dressing. Urge compliance with the prescribed antibiotic treatment, and promote regular followup care.
  • If the patient is diabetic, evaluate him for malignant otitis externa.

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