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| {{Infobox_Disease
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| | Name = {{PAGENAME}}
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| | Image = Gray1193.png
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| | Caption = Side view of head, showing surface relations of bones. (Mastoid process labeled near center.)
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| | DiseasesDB = 22479
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| }}
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| __NOTOC__ | | __NOTOC__ |
| {{Search infobox}}
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| {{CMG}}
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| ==Overview==
| | {{CMG}}; {{AE}}{{MJ}} |
| '''Mastoiditis''' is an infection of the [[mastoid process]], the portion of the [[temporal bone]] of the [[skull]] that is behind the [[ear]]. It is usually caused by untreated acute [[otitis media]] (middle ear infection) and used to be a leading cause of child mortality. With the development of [[antibiotic]]s, however, mastoiditis has become quite rare in developed countries, most likely due to antibiotic treatment of otitis media before it can spread. It is treated with medications and/or surgery. If untreated, the infection can spread to surrounding structures, including the [[brain]], causing serious complications.
| | {{Mastoiditis}} |
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| ==Epidemiology==
| | {{SK}} Mastoid inflammation, Mastoid empyema, Inflammation of mastoid |
| In the United States and other developed countries, the [[incidence (epidemiology)|incidence]] of mastoiditis is quite low, around 0.004%, although it is higher in developing countries. The most common ages affected are 6–13 months, as it is during that age that ear infections are most common. Males and females are equally affected.
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| ==Pathophysiology== | | ==[[Mastoiditis overview|Overview]]== |
| The pathophysiology of mastoiditis is straightforward: bacteria spread from the middle ear to the mastoid air cells, where the inflammation causes damage to the bony structures. The bacteria most commonly observed to cause mastoiditis are ''[[Streptococcus pneumoniae]]'', ''[[Streptococcus pyogenes]]'', ''[[Staphylococcus aureus]]'', and [[gram-negative]] [[bacilli]]. Other bacteria include ''[[Moraxella catarrhalis]]'', ''[[Streptococcus pyogenes]]'', and rarely, ''[[Mycobacterium]]'' species. Some mastoiditis is caused by [[cholesteatoma]], which is a sac of keratinizing squamous epithelium in the middle ear that usually results from repeated middle-ear infections. If left untreated, the cholesteatoma can erode into the mastoid process, producing mastoiditis, as well as other complications.
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| ==Symptoms and Signs== | | ==[[Mastoiditis historical perspective|Historical Perspective]]== |
| Some common [[symptoms]] and signs of mastoiditis include pain and tenderness in the mastoid region, as well as swelling. There may be ear pain ([[otalgia]]), and the ear or mastoid region may be red (erythematous). Fever or headaches may also be present. Infants usually show nonspecific symptoms, such as [[anorexia (symptom)|anorexia]], [[diarrhea]], or [[irritability]]. Drainage from the ear occurs in more serious cases.
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| ==Prognosis== | | ==[[Mastoiditis classification|Classification]]== |
| With prompt treatment, it is possible to cure mastoiditis. Seeking medical care early is important. However, it is difficult for antibiotics to penetrate to the interior of the mastoid process and so it may not be easy to cure the infection; it also may recur. Mastoiditis has many possible complications, all connected to the infection spreading to surrounding structures. [[Hearing loss]] may result, or inflammation of the [[labyrinth (inner ear)|labyrinth]] of the [[inner ear]] ([[labyrinthitis]]) may occur, producing [[Vertigo_(medical)|vertigo]]. The infection may also spread to the [[facial nerve]] (cranial nerve VII), causing [[facial-nerve palsy]] which can produce weakness or paralysis of some facial muscles on that side of the face. Other complications include [[Bezold's abscess]], an abscess (a collection of pus surrounded by inflamed tissue) behind the [[sternocleidomastoid muscle]] in the neck, or a subperiosteal abscess, between the periosteum and mastoid bone ( resulting in the typical appearance of a protruding ear). Serious complications result if the infection spreads to the brain. These include [[meningitis]] (inflammation of the protective membranes surrounding the brain), [[epidural abscess]] (abscess between the skull and outer membrane of the brain), dural venous [[thrombophlebitis]] (inflammation of the [[vein|venous]] structures of the brain), or [[brain abscess]].
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| ==Diagnosis== | | ==[[Mastoiditis pathophysiology|Pathophysiology]]== |
| The diagnosis of mastoiditis is clinical—based on the [[medical history]] and [[physical examination]]. Imaging studies may provide additional information; the study of choice is the [[CT scan]], which may show focal destruction of the bone or signs of an [[abscess]] (a pocket of infection). [[X-rays]] are not as useful. If there is drainage, it is often sent for [[microbiological culture|culture]], although this will often be negative if the patient has begun taking antibiotics.
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| ==Treatment== | | ==[[Mastoiditis causes|Causes]]== |
| The primary treatment for acute mastoiditis without [[osteitis]] is the administration of [[intravenous]] [[antibiotics]]. The choice of antimicrobial agents is similar to that for [[otitis media|acute otitis media]]—antibiotics against ''[[Streptococcus pneumoniae]]'' and ''[[Haemophilus influenzae]]''. Additional coverage for ''[[Staphylococcus aureus]]'' and [[Gram-negative bacilli]] may be considered for protracted disease until the results of cultures become available.<ref name="pmid18092706">{{cite journal| author=Ramakrishnan K, Sparks RA, Berryhill WE| title=Diagnosis and treatment of otitis media. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 11 | pages= 1650-8 | pmid=18092706 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18092706 }} </ref><ref>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref> [[Ciprofloxacin]] (500 mg twice a day) may be considered in [[immunocompromised]] patients with [[diabetes]] or [[HIV infection]] or in infections involving the skin and periauricular areas. Long-term antibiotics may be necessary to completely eradicate the infection. [[Otalgia]] associated with otitis externa may be managed with topical anesthesic agent such as [[benzocaine]].
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| ===Antibiotic Therapy=== | | ==[[Differentiating mastoiditis from other diseases|Differentiating Mastoiditis from other Diseases]]== |
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| ====Acute Mastoiditis==== | | ==[[Mastoiditis epidemiology and demographics|Epidemiology and Demographics]]== |
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| =====Preferred Regimen===== | | ==[[Mastoiditis risk factors|Risk Factors]]== |
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| {{abx|Ceftriaxone 2 gm IV qd|Levofloxacin 750 mh IV qd}}
| | ==[[Mastoiditis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ====Acute Exacerbation of Chronic Otitis Media==== | | ==Diagnosis== |
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| =====Preferred Regimen=====
| | [[Mastoiditis history and symptoms|History and Symptoms]] | [[Mastoiditis physical examination|Physical Examination]] | [[Mastoiditis laboratory findings|Laboratory Findings]] | [[Mastoiditis x ray|X ray]] | [[Mastoiditis CT|CT scan]] | [[Mastoiditis MRI|MRI]] | [[Mastoiditis ultrasound|Ultrasound]] | [[Mastoiditis other imaging findings|Other Imaging Findings]] | [[Mastoiditis other diagnostic studies|Other Diagnostic Studies]] |
| {{abx|Vancomycin (trough: 15–20 mcg/mL)}} {{and}} {{abx|Piperacillin-Tazobactam 3.375 g IV q6h}}
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| =====Alternative Regimen===== | | ==Treatment== |
| {{abx|Vancomycin (trough: 15–20 mcg/mL)}} {{and}} {{abx|Ciprofloxacin 400 mg IV q8h}}
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| ===Surgery===
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| If the condition does not respond to antibiotics or is associated with osteitis, surgical procedures may be performed while continuing the medication. The most common procedure is [[myringotomy]] with [[tympanostomy tube]] placement for drainage and culture of effusion. When an [[abscess]] has formed in the [[mastoid bone]], a [[mastoidectomy]] should be performed after antimicrobial agents have controlled [[sepsis]].
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| ==Prevention==
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| In general, mastoiditis is rather simple to prevent. If the patient with an ear infection seeks treatment promptly and receives complete treatment, the antibiotics will usually cure the infection and prevent its spread. For this reason, mastoiditis is rare in developed countries.
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| ==Gallery==
| | [[Mastoiditis medical therapy|Medical Therapy]] | [[Mastoiditis surgery|surgery]] | [[Mastoiditis primary prevention|Primary Prevention]] | [[Mastoiditis secondary prevention|Secondary Prevention]] | [[Mastoiditis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Mastoiditis future or investigational therapies|Future or Investigational Therapies]] |
| <gallery heights="125" widths="200">
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| Image:Mastoidectomy Arrowheads LABELED.jpg|Picture of a right mastoidectomy, surgeon's view. Note the blue color of the skeletonized sigmoid sinus.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy labeled1.jpg|Picture of a left mastoidectomy, surgeon's view.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy labeled.jpg|In this left canal wall up mastoidectomy, the tympanic membrane has been elevated forward and a cholesteatoma sac is visible in the attic.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoid cutaneous fistula trim.jpg|This patient has a recurrent cholesteatoma which has found its way to the surface of the post-auricular skin, forming a mastoid cutaneous fistula.<ref>http://www.ghorayeb.com</ref>
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| Image:Cholesteatoma sac eroding mastoid.jpg|This cholesteatoma sac has eroded the lateral surface of the mastoid bone and was found immediately under the post-auricular skin.<ref>http://www.ghorayeb.com</ref>
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| Image:Mastoidectomy Bowl.jpg|Left canal wall down mastoidectomy.This patient had a modified radical mastoidectomy with tympanoplasty. The posterior bony canal has been removed and part of the dry "mastoid bowl" is visible posterior and superior to the reconstructed tympanic membrane <ref>http://www.ghorayeb.com</ref>.
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| Image:Mastoidectomy Bowl 008.jpg|Magnification of the previous picture <ref>http://www.ghorayeb.com</ref>.
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| </gallery>
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
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| ==Further Reading==
| | {{Diseases of the ear and mastoid process}} |
| * Durand, Marlene & Joseph, Michael. (2001). Infections of the Upper Respiratory Tract. In Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, & J. Larry Jameson (Eds.), ''Harrison's Principles of Internal Medicine'' (15th Edition), p. 191. New York: McGraw-Hill
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| * "[http://www.nlm.nih.gov/medlineplus/ency/article/001034.htm Mastoiditis]" (July 30, 2003). MedlinePlus Medical Encyclopedia.
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| {{Diseases of the ear and mastoid process}} | | {{WikiDoc Help Menu}} |
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| [[Category:Disease]]
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| [[Category:Infectious disease]]
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| [[Category:Primary care]] | | [[Category:Emergency mdicine]] |
| [[Category:Skeletal disorders]] | | [[Category:Disease]] |
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