Patient Presentation
A 24-month-old female came to clinic after 7 days of various symptoms. Initially she started to have a low grade fever that responded well to anti-pyretics. Two days later she non-specifically stated that her ears hurt. Her fever continued and two days later she was seen and her examination was normal including her ears. One day later her left ear seemed to be sticking out and she was seen in the emergency room. The physician noted slight erythema of the posterior ear, but with a normal tympanic membrane. Otolaryngology was informally consulted and suggested to use amoxicillin-clavulanate antibiotic. She was seen in clinic two days later with her ear being more prominently displaced anteriorly. She was also fussier and not sleeping well. Her fever continued to be < 101° F. No trauma or foreign bodies were reported.
The past medical history revealed a fully immunized healthy child who attended a group childcare home 2 days/week.
The family history was non-contributory. The review of systems showed no dizziness or ataxia.
The pertinent physical exam showed an unhappy female with normal vital signs and growth parameters. She had a protuberant left ear that was erythematous and tender posteriorly involving the mastoid prominence along the outline of the pinna. The neck was not involved and had full range of motion. Her left tympanic membrane was non-erythematous with some fluid noted. The right tympanic membrane was normal. She had shoddy anterior cervical lymph nodes and groin nodes. She had a normal neurological examination and the rest of the examination was normal.
The diagnosis of mastoiditis was made. The radiologic evaluation of a computed tomograph of the head showed fluid involving the left mastoid aircells with adjacent soft tissue swelling and abscess but without bony destruction. The patient was taken to the operating room for placement of bilateral pressure equalizing tubes for drainage. The otolaryngologists noted she had a ‘peel’ that covered the tympanic membrane that was giving a falsely non-erythematous visual examination of her left tympanic membrane. She was placed on ceftriaxone intravenously. Cultures of the middle ear fluid eventually were negative.
The patient’s clinical course showed no improvement over the next 1.5 days and a repeat computed tomography exam also showed no improvement in the abscess. She was again taken to the operating room for incision and drainage. She then improved clinically in the next 24 hours and was discharged home to finish 14 days of oral antibiotics. Three weeks later her audiogram showed slightly abnormal hearing on the left.
Figure 75 – Axial computed tomography image obtained with intravenous contrast from an exam of the maxillofacial region in bone (above) and soft tissue (below) windows. On the bone window image, the right mastoid air cells are clear and the left mastoid air cells are opacified, representing left mastoiditis. Additionally, on the soft tissue window image, just lateral to the left mastoid air cells in the soft tissues, there is a low density fluid collection with an enhancing rim that represents a Bezold’s abscess. There was no evidence of bony destruction, venous sinus thrombosis, or intracranial extension.
Discussion
Children have been having problems with their ears for centuries.
Dr. Thomas Morgan Rotch in the first edition of his pediatric text quoted the also famous German otologist, Dr. Anton Von Tröltsch, who said “there is an unusually strong disposition to disease of the middle ear, owning on the one hand to the double influence of the peculiar morphological relations of the ear and the pharynx, and on the other hand to the disease and conditions of life to which the child is frequently exposed.”
Mastoiditis is an inflammatory process of the mastoid air cells. The mastoid is contiguous with the middle ear cleft and therefore it is involved in most patients with acute otitis media. However, acute mastoiditis occurs when the infection spreads beyond the mucosa of the middle ear cleft, there is osteitis in the air-cell system, or there is mastoid process periostitis. These are usually caused by direct bony erosion or through the emissary vein of the mastoid indirectly.
In the pre-antibiotic era, mastoiditis was a common and feared complication of otitis media in up to 20% of all cases. Treatment was surgical but still complications and death were all too common. The John Simon Guggenheim Foundation which offers numerous annual international fellowships was begun in 1925 after the eldest son of philanthropist Simon Guggenheim reportedly died from mastoiditis. A 1946 study by House documented an 80% decrease in the number of mastoidectomies performed after antibiotics began being significantly used for otitis media treatment.
Children with mastoiditis are usually young (< 2 years of age). Mastoiditis can present with otalgia, fever, hearing loss, abnormal tympanic membrane, otorrhea, posterior auricular erythema or edema, and protuberance of the pinna. Persistent otorrhea and otalgia while on oral antibiotics especially with any neurological symptoms suggest complications of otitis media and the need for further evaluation. Organisms commonly found in mastoiditis include Streptococcus pneumoniae, Staphylococcus pyogenes, Haemophilus influenza, non-typeable Proteus mirabilis, and Pseudomonas aeruginosa. Mastoiditis can be treated with myringotomy (and/or pressure-equalizing tube placement), abscess drainage or mastoidectomy.
Learning Point
Mastoiditis complications include:
- Bacteremia – with subsequent seeding of other body parts including lung embolization
- Central Nervous System
- Epidural abscess
- Subdural abscess
- Hearing loss – temporary and permanent
- Meningitis
- Sigmoid sinus thrombosis – extension of the septic thrombosis posteriorly can cause blockage of the arachnoid granulations and subsequent otogenic hydrocephalus.
- Other central nervous system thromboses – cavernous sinus, petrous sinus
- Osteomyelitis of the skull
- Cardiovascular system
- Peripheral thromboses – usually from extension downward from the central nervous system – internal jugular vein, subclavian vein, superior vena cava
- Carotid artery – abscess, arteritis, spasms
- Other
- Bezold abscess – pus in the sternocleidomastoid muscle
- Facial nerve paralysis
- Death
Questions for Further Discussion
1. What duration of antibiotics is recommended for mastoiditis?
2. How commonly does mastoiditis recur?
3. When should a child have an evaluation for a possible immunodeficiency after having mastoiditis?
Related Cases
- Disease
Mastoiditis
Ear Disorders
Ear Infections
- Symptom/Presentation
Fever and Fever of Unknown Origin
Hearing Problem
Mass or Swelling
Ear Pain
- Specialty
General Pediatrics
Emergency Medicine
Medical History
Otolaryngology
Radiology / Nuclear Medicine / Radiation Oncology
- Age
Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Rotch, TM. Pediatrics. The Hygenic and Medical Treatment of Children. J.B. Lippincott Co., Philadelphia, PA. 1896:1106.
House H. Acute otitis media. A comparative study of the results obtain in therapy before and after the introduction of the sulfonamide compounds. Arch. Otolaryngol. Head Neck Surg. 1946:43;371-78.
Redaelli de Zinis LO, Gasparotti R, Campovecchi C, Annibale G, Barezzani MG. Internal jugular vein thrombosis associated with acute mastoiditis in a pediatric age. Otol Neurotol. 2006 Oct;27(7):937-44.
Spratley J, Silveira H, Alvarez I, Pais-Clemente M. Acute mastoiditis in children: review of the current status. Int J Pediatr Otorhinolaryngol. 2000 Nov 30;56(1):33-40.
Go C, Bernstein JM, de Jong AL, Sulek M, Friedman EM. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol. 2000 Apr 15;52(2):143-8.
Brook I, Donaldson, JD.Mastoiditis. eMedicine. Available from the Internet at http://emedicine.medscape.com/article/966099-overview (rev. 07/30/2008, cited 2/11/2009).
Ferguson A. Campus Benefactors: Simon Guggenheim. Colorado School of Mines “The OreDigger Newspaper”. Available from the Internet at http://media.www.oredigger.net/media/storage/paper1162/news/2009/02/09/Features/Campus.Benefactors.Simon.Guggenheim-3618459.shtml (rev. 2/9/09, cited 2/11/09).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Steve Randall, MD, MPH.
Pediatric Resident, University of Iowa Children’s Hospital.
Pediatric Education 