What is Mastoiditis and how to manage it?
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Mastoiditis is a bacterial infection of the mastoid air cells in the temporal bone, typically a complication of acute otitis media (AOM). Though less common due to widespread antibiotic use, it remains an ENT emergency due to potential intracranial and extracranial complications.
Clinical features
Symptoms often follow an episode of AOM and may include:
- Fever
- Otalgia (often severe and persistent)
- Otorrhoea (if tympanic membrane perforated)
- Mastoid tenderness or swelling
- Displaced pinna (down and out)
- Hearing loss
In infants, signs can be non-specific: irritability, poor feeding, and fever.
Examination findings
- Erythematous, bulging tympanic membrane or perforation
- Tenderness or fluctuant swelling over mastoid process
- Protrusion of auricle
Consider alternative diagnoses such as cellulitis, lymphadenitis, or other causes of retroauricular swelling.
Investigations
- Primarily a clinical diagnosis
- Consider ENT referral for imaging (CT temporal bones) if:
- Complications suspected (e.g. intracranial extension, abscess)
- Atypical presentation
- Failure to improve
Management
Immediate referral to ENT is advised for suspected mastoiditis.
- IV antibiotics (e.g. ceftriaxone or cefotaxime)
- Myringotomy ± grommet insertion
- Mastoidectomy if abscess or failure to respond
Delay in treatment can lead to serious complications such as:
- Subperiosteal abscess
- Facial nerve palsy
- Meningitis
- Lateral sinus thrombosis
- Intracranial abscess
When to suspect complications
Escalate urgently if:
- Neurological signs
- Severe headache or photophobia
- Neck stiffness
- Altered consciousness
- Persistent fever despite treatment
Follow-up and prevention
- Follow-up with ENT
- Ensure AOM is treated appropriately in children
- Consider vaccination status (pneumococcal, Hib)