Paeds · ent-hearing-and-oral-health
Mastoiditis and otogenic complications
Also known as Acute mastoiditis · Coalescent mastoiditis · Masked mastoiditis · Bezold abscess · Gradenigo syndrome · Lateral sinus thrombosis · Otitic hydrocephalus · Otogenic intracranial complications
Fellowship topic on mastoiditis and otogenic complications in children: acute mastoiditis as the commonest suppurative complication of acute otitis media through the contiguous mastoid air-cell system; coalescent and masked forms; the intratemporal complications from subperiosteal and Bezold abscess through Gradenigo petrositis, facial palsy and labyrinthitis to lateral sinus thrombosis; the intracranial complications of meningitis, extradural and subdural empyema, brain abscess and otitic hydrocephalus; the postauricular swelling and the down-and-out pinna, the Streptococcus pneumoniae, pyogenes, Staphylococcus aureus and Pseudomonas microbiology; the contrast temporal-bone CT findings of coalescence; the intravenous antibiotic regimen and the cortical mastoidectomy, myringotomy and needle-aspiration decisions; and ANZ, UK and North American guidance.
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Target exams
Red flags
- A febrile, irritable child with postauricular swelling, erythema and tenderness, a down-and-out pinna and a bulging erythematous tympanic membrane — acute mastoiditis; admit for intravenous antibiotics and urgent ear-nose-and-throat review
- A fluctuant postauricular or neck mass below the mastoid tip — a subperiosteal or Bezold abscess that needs imaging, intravenous antibiotics and surgical drainage
- Severe headache, vomiting, altered conscious state, meningism, focal neurology or seizures in a child with ear disease — intracranial extension: meningitis, extradural or subdural empyema, or brain abscess
- Spiking picket-fence fevers, papilloedema, abducens palsy or a Gradenigo triad of discharging ear, retro-orbital pain and lateral rectus palsy — lateral sinus thrombosis and petrous apicitis
- No improvement or deterioration after 48 hours of intravenous antibiotics — search for a subperiosteal abscess, lateral sinus thrombosis or intracranial collection needing surgery
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and ENT: acute mastoiditis as a suppurative complication of acute otitis media — recognition of the postauricular signs, the down-and-out pinna, and stepwise intravenous antibiotic management
- Infectious diseases: otogenic intracranial and intratemporal complications, the causative organisms, and the threshold for contrast temporal-bone CT
- Renewed curriculum — Infectious diseases and emergency care: mastoiditis as a sight-, hearing- and life-threatening emergency, the coalescent and masked forms, and the cortical mastoidectomy decision
- ENT and neurology: lateral sinus thrombosis, Gradenigo syndrome, otitic hydrocephalus and intracranial extension
- General Paediatrics: distinguishing mastoiditis from uncomplicated acute otitis media, when to image, when to refer to ENT and the intravenous antibiotic regimen
- Emergency care: resuscitation of the febrile child with mastoiditis and sepsis, and escalation to ENT and neurosurgery for intracranial complications
- Long Case / Structured discussion: a child with acute mastoiditis and a subperiosteal abscess or lateral sinus thrombosis — diagnosis, imaging, medical versus surgical management and complications
- Communication station: explaining the diagnosis of mastoiditis, the need for admission and intravenous antibiotics, and the surgical decision to a family
- Level 2 / 3 — Infection and ENT: acute mastoiditis and the complications of otitis media, antimicrobial stewardship and the surgical threshold
- Emergency and acute care: the child with a swollen painful ear — recognition of the mastoiditis emergency and its intracranial spread
- Foundation of Practice (FOP): the mastoid air-cell anatomy, the coalescent CT finding, the postauricular signs and the causative organisms
- Applied Knowledge in Practice (AKP): CT indications, intravenous antibiotic choice, the Gradenigo triad and the surgical criteria for cortical mastoidectomy
- History-taking and management: the child with postauricular swelling and fever and the recognition of acute mastoiditis
- Communication: explaining admission, intravenous antibiotics and the surgical decision to a family
- General Pediatrics Content Outline — mastoiditis and otogenic complications: diagnosis, treatment and complications
- Infectious Diseases and ENT: otitis media suppurative complications, S. pneumoniae and S. pyogenes mastoiditis, lateral sinus thrombosis and intracranial extension
- Otolaryngology: subperiosteal and Bezold abscess, Gradenigo syndrome, facial palsy and the medical-versus-surgical approach
- Patient Care: recognition and stepwise management of mastoiditis and its otogenic complications across severity, with timely imaging and multidisciplinary referral
- Systems-Based Practice: coordinated care with ENT, neurosurgery, audiology and infectious diseases, and safe disposition and hearing follow-up
- Medical Knowledge: mastoid air-cell anatomy, the routes of spread, the microbiology and the antibiotic selection
- Medical Expert: mastoiditis and otogenic complications diagnosis, imaging, treatment and complications
- Collaborator: multidisciplinary management with ENT, neurosurgery and infectious diseases
- Communicator: explaining the severity, the admission plan and the surgical decision to a family
The aditus is the gate — AOM versus acute mastoiditis
Uncomplicated acute otitis media
Acute mastoiditis
Overview & Definition
Picture a fourteen-month-old brought to the emergency department with three days of fever, a runny nose and ear-pulling. The ear looked red yesterday and the family doctor started oral amoxicillin. Today the child is more unsettled, the temperature is 39.2 degrees Celsius, and behind the right ear the skin is red, swollen and tender to touch, with the pinna sitting lower and jutting further out than the left. This is acute mastoiditis, and the shift from a treatable ear infection to a surgical threat has happened overnight. The clinician's job is to see the postauricular change, to start intravenous antibiotics and to involve the ear-nose-and-throat surgeon before the infection erodes the cortical bone and reaches the neck, the venous sinuses or the brain. [4] [5]
The mastoid process is the bony prominence behind the pinna, and in the older child and adult it is honeycombed with air cells that open into the middle ear through the aditus ad antrum. Because this connection is wide and valveless, middle-ear infection reaches the mastoid in nearly every case of AOM. Acute mastoiditis is symptomatic inflammation and suppuration of these air cells with the clinical signs of postauricular inflammation — the stage at which the inflamed but draining mastoid of simple AOM has become an infected, obstructed cavity. [9] The inflammation moves through a continuum: an early mucosal stage, then empyema of the air cells, then coalescence as the rising pressure and osteitis dissolve the thin bony trabeculae and threaten the cortical plates. [5]
Most acute mastoiditis resolves with prompt intravenous antibiotics, and the modern child who reaches hospital early rarely needs surgery. The danger lies in the complications that follow when the cortical bone is breached: the intratemporal collections in the neck and petrous apex, the facial nerve and labyrinth, and the intracranial structures reached through the tegmen, the sigmoid plate and the valveless venous channels. The task is layered — recognise the postauricular signs, image for the complication, treat with broad intravenous antibiotics, and time the surgical drainage so that the abscess is drained and the sinus decompressed before hearing, the facial nerve or the brain is lost. [1] [3]
References11ShowHide
- [1]Go C; Bernstein JM; de Jong AL; Sulek M; et al Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol, 2000.PMID 10767461
- [2]Penido Nde O; Borin A; Iha LC; Suguri VM; et al Intracranial complications of otitis media: 15 years of experience in 33 patients. Otolaryngol Head Neck Surg, 2005.PMID 15632907
- [3]Lavin JM; Rusher T; Shah RK Complications of Pediatric Otitis Media. Otolaryngol Head Neck Surg, 2016.PMID 26494054
- [4]Mattos JL; Colman KL; Casselbrant ML; Chi DH Intratemporal and intracranial complications of acute otitis media in a pediatric population. Int J Pediatr Otorhinolaryngol, 2014.PMID 25447953
- [5]Zevallos JP; Vrabec JT; Williamson RA; Giannoni C; et al Advanced pediatric mastoiditis with and without intracranial complications. Laryngoscope, 2009.PMID 19504555
- [6]Enoksson F; Groth A; Hultcrantz M; Stalfors J; et al Subperiosteal abscesses in acute mastoiditis in 115 Swedish children. Int J Pediatr Otorhinolaryngol, 2015.PMID 26022749
- [7]Bartov N; Lahav Y; Lahav G; Zloczower E; et al Management of Acute Mastoiditis With Immediate Needle Aspiration for Subperiosteal Abscess. Otol Neurotol, 2019.PMID 31135677
- [8]Loh R; Phua M; Shaw CL Management of paediatric acute mastoiditis: systematic review. J Laryngol Otol, 2018.PMID 28879826
- [9]Minks DP; Porte M; Jenkins N Acute mastoiditis--the role of radiology. Clin Radiol, 2013.PMID 22980753
- [10]O'Connor TE; Perry CF; Lannigan FJ Complications of otitis media in Indigenous and non-Indigenous children. Med J Aust, 2009.PMID 19883359
- [11]Kuczkowski J; Dubaniewicz-Wybieralska M; Przewoźny T; Narozny W; et al Otitic hydrocephalus associated with lateral sinus thrombosis and acute mastoiditis in children. Int J Pediatr Otorhinolaryngol, 2006.PMID 16899305