Mastoiditis surgery: Difference between revisions

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{{Mastoiditis}}
{{Mastoiditis}}


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==Overview==
==Overview==
Different [[surgical procedures]] may be performed to treat mastoiditis. [[Myringotomy]] is surgical perforation of the [[tympanic membrane]]. It should be considered the primary treatment in all cases of [[infectious]] mastoiditis following [[otitis media]], particularly when there is an unperforated [[tympanic membrane]] or inadequate drainage. [[Tympanocentesis]] should be performed in all mastoiditis patients to obtain [[middle ear]] fluid for culture and susceptibility testing. [[Myringotomy]] accompanied by the additional insertion of a [[tympanostomy tube]] is indicated in some cases, such as [[Eustachian tube]] dysfunction, [[suppurative]] complications requiring additional drainage, and when [[tympanic membrane]] must be repaired from [[Eustachian tube dysfunction]]. Definitive surgery is [[mastoidectomy]], which is the surgical removal of the [[mastoid]] cortical bone and underlying [[Mastoid air cells|air cells]]. Indications for [[mastoidectomy]] may include subperiosteal [[abscess]] such as postauricular fluctuance or mass, [[chronic]] [[suppurative]] [[otitis media]] or [[cholesteatoma]], progression of postauricular swelling or fluctuance, [[fever]], and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and [[myringotomy]].


==Surgery==
== Surgical procedures and indications ==
Different [[surgical procedures]] may be performed to treat mastoiditis:<ref name="pmid16413617">{{cite journal |vauthors=Zanetti D, Nassif N |title=Indications for surgery in acute mastoiditis and their complications in children |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=70 |issue=7 |pages=1175–82 |year=2006 |pmid=16413617 |doi=10.1016/j.ijporl.2005.12.002 |url=}}</ref><ref name="urlPediatric Guidelines: Head and Neck Infections - Mastoiditis | Infectious Diseases Management Program at UCSF">{{cite web |url=http://idmp.ucsf.edu/pediatric-guidelines-head-and-neck-infections-mastoiditis |title=Pediatric Guidelines: Head and Neck Infections - Mastoiditis &#124; Infectious Diseases Management Program at UCSF |format= |work= |accessdate=}}</ref><ref name="pmid197344392">{{cite journal|year=2010|title=Clinical strategies for the management of acute mastoiditis in the pediatric population|url=|journal=Clin Pediatr (Phila)|volume=49|issue=2|pages=110–5|doi=10.1177/0009922809344349|pmid=19734439|vauthors=Lin HW, Shargorodsky J, Gopen Q}}</ref><ref name="pmid197587112">{{cite journal|year=2009|title=Mastoiditis in a paediatric population: a review of 11 years experience in management|url=|journal=Int. J. Pediatr. Otorhinolaryngol.|volume=73|issue=11|pages=1520–4|doi=10.1016/j.ijporl.2009.07.003|pmid=19758711|vauthors=Pang LH, Barakate MS, Havas TE}}</ref>
=== Incision and drainage of the mastoid abscess: ===
When fluctuation presents, drainage must be done immediately to achieve complete drainage of the [[pus]].


=== Surgical treatment in mastoiditis should be done in below conditions ===
=== Myringotomy ===
* Intracranial complications.
[[Myringotomy]] is the surgical perforation of the [[tympanic membrane]].
* Cholesteatoma.
* It should be considered a primary treatment in all cases of [[infectious]] mastoiditis when there is an unperforated [[tympanic membrane]] or inadequate drainage.  
* Not achieving adequate response after 24 to 48 hours of starting treatment
* [[Myringotomy]] may be done with or without [[tympanostomy tube]] placement.
* Evidence of postauricular fluctuation and subperiosteal abscess.
* Diagnosis of acute coalescent mastoiditis.
* Otorrhoea persisting for more than 2 weeks despite adequate antibiotic treatment.


=== Minimally invasive procedures: ===
=== Tympanocentesis ===
: ''Incision and drainage of the mastoid abscess'': when fluctuation presents drainage must be done immidiately. The incision should be in line with any future surgical incisions. Hilton’s method is used to open all the abscess loculi and to achieve complete drainage of the pus. A pack of gauze soaked with Betadine can be placed in the abscess cavity and changed daily with wound nursing.
[[Tympanocentesis]] should be done in all mastoiditis patients to obtain [[middle ear]] fluid for culture and susceptibility testing.
; b.
===Tympanostomy tube===
: ''Myringotomy'': with or without tympanostomy tube placement. It should be considered as an established treatment in every case of mastoiditis with an intact tympanic membrane or inadequate drainage.
[[Myringotomy]] accompanied by the additional insertion of a [[tympanostomy tube]] is indicated in the following:
:; a.
*[[Eustachian tube]] dysfunction
:: Definitive surgery:
*[[Suppurative]] complications requiring additional drainage via the [[tympanostomy tube]]
::; •
*Necessity to repair the [[tympanic membrane]] from [[Eustachian tube]] dysfunction
::: If cholesteatoma is present, an open mastoidectomy should be performed.
[[Otorrhea]] is a possible complication of performing a [[myringotomy]] with a [[tympanostomy tube]], affecting up to 17% of infected ears.<sup>[[Otitis media surgery#cite note-pmid18697973-3|[3]]]</sup>
::; •
::: If cholesteatoma is not found, cortical mastoidectomy is the best choice.
A postauricular fistula (Fig. 3) should be followed through the mastoid and totally excised, the skin edges should be freshened, undermined and carefully sutured in 2 layers.


The timing of surgery depends mainly on the patient’s condition and his response to the medical treatment. If the patient is deteriorating, surgery should be carried out promptly to save the patient’s life.
=== Mastoidectomy ===
Definitive surgery is [[mastoidectomy]], which is the surgical removal of the [[mastoid]] cortical bone and underlying [[Mastoid air cells|air cells]].
==== Methods ====
* Cortical [[mastoidectomy]] is the best choice of therapy.  
* Open [[mastoidectomy]] should be performed if [[cholesteatoma]] is present.
* Simple [[mastoidectomy]] is performed to clean out the [[mastoid]] infection and provide external drainage
* Radical [[mastoidectomy]] is performed only when there is no clinical response to simple [[mastoidectomy]], as evidenced by continued [[otorrhea]] or [[pain]].
==== Indications for mastoidectomy may include: ====
* [[Subperiosteal]] [[abscess]] such as postauricular fluctuance or [[mass]]
* Coalescent mastoiditis in [[CT scan]] (regardless of other clinical features)
* Chronic [[suppurative]] [[otitis media]] or [[cholesteatoma]]
* Progression of postauricular [[swelling]] or fluctuance, [[fever]], and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and [[myringotomy]]


However, if the patient’s response to medical treatment is good, as evidenced by clinical improvement and a follow-up CT scan, the surgery may be postponed for one week to avoid perichondritis.
=== The following video presents surgical procedures for mastoiditis: ===
 
{{#ev:youtube|jnonLwxW2Cg}}
=== 5.3. Guidelines of management of mastoid abscess according to aetiopathology ===
; 1.
: Acute coalescent mastoiditis without abscess formation.
:; •
:: Treatment is mainly medical in the form of intravenous antibiotics according to culture and sensitivity.
:; •
:: Myringotomy is needed in cases with insufficient drainage e.g. intact drum or small high perforation.
:; •
:: Treatment of the cause e.g. acute suppurative otitis media
; 2.
: Acute coalescent mastoiditis presenting with a complication e.g. facial nerve paralysis or intracranial complications e.g. lateral sinus thrombophlebitis.
:; •
:: Treatment is mainly surgical under cover of broad spectrum intravenous antibiotics.
:; •
:: Treatment of the cause.
:; •
:: Intracranial complications such as brain abscess or meningitis should be co-managed with the neurosurgery department with priority going to the neurosurgery. When the patient is neurologically stable, management of the ear disease can be addressed.
; 3.
: Acute mastoiditis with postauricular abscess.
:; •
:: Treatment is surgical in the form of cortical mastoidectomy after medical preparation with intravenous antibiotics.
:; •
:: In unfavourable circumstances, the abscess may be incised and drained followed a few days later by mastoidectomy.
:; •
:: Treatment of the cause.
; 4.
: Acute mastoiditis complicating safe type of chronic suppurative otitis media.
:; •
:: Medical treatment similar to acute suppurative otitis media.
:; •
:: Treatment of the cause after the abscess has resolved e.g. tympanoplasty with cortical mastoidectomy.
; 5.
: Acute mastoiditis on top of unsafe type of chronic suppurative otitis media (cholesteatoma).
:; •
:: Treatment is surgical in the form of open mastoidectomy under cover of intravenous broad spectrum antibiotic.
 
Mastoidectomy is indicated in children who do not demonstrate adequate treatment response after 24 to 48 hours. Imaging of the temporal bone also may be indicated (to evaluate the development of intratemporal complications) [1,6].
 
Similarly, patients with acute mastoid osteitis or complications who have been treated with intravenous antibiotics, myringotomy, and mastoidectomy should demonstrate clinical improvement within 24 to 48 hours of initiation of treatment. Radical mastoidectomy may be indicated for patients with persistent symptoms [1]. Imaging of the temporal bone also may be indicated (to evaluate the development of intratemporal complications) [1,6].
 
Acute mastoiditis with extracranial or intracranial complications is usually treated with IV antibiotics, myringotomy with or without placement of a tympanostomy tube, and mastoidectomy [1,15,19,21]. However, we suggest that acute mastoiditis complicated by isolated facial nerve palsy be treated initially with IV antimicrobial therapy and myringotomy with or without placement of a tympanostomy tube [12]. (See 'Uncomplicated disease' above.)
 
We suggest that children with suppurative complications of acute mastoiditis other than facial nerve palsy be treated with IV antimicrobial therapy, myringotomy with or without placement of a tympanostomy tube, and mastoidectomy. (See 'Antimicrobial therapy' below and 'Drainage' below.)
 
Simple mastoidectomy in combination with antimicrobial therapy and tympanostomy tube placement is usually indicated as initial management when a subperiosteal abscess is noted at presentation [12,15]. However, some experts favor postauricular aspiration as the initial procedure [22].
 
Additional surgical interventions may be necessary for children with suppurative intratemporal or intracranial complications (eg, drainage of subperiosteal, subcutaneous, intratemporal, or intracranial collections, or thrombectomy) [1,11].
 
DRAINAGE — Treatment of acute mastoiditis usually requires the drainage of pus from the middle ear and/or mastoid cavity. Although there are reports of successful treatment without tympanocentesis or myringotomy [3], aspiration of middle-ear fluid is crucial in guiding definitive antimicrobial therapy. In addition, early drainage may interrupt the pathologic process and prevent complications [9]. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Pathogenesis' and "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications'.)
 
The indications for the various drainage procedures (tympanocentesis, myringotomy, myringotomy with placement of tympanostomy tube, mastoidectomy) vary from center to center depending on the pathologic stage (acute mastoiditis with periosteitis versus coalescent mastoiditis) and presence or absence and type of complications [1,11,27]. (See 'Overview of management' above.)
 
●Tympanocentesis – At a minimum, tympanocentesis should be performed in all children with mastoiditis to obtain middle-ear fluid for culture and susceptibility testing [1]. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Microbiologic studies'.)
 
●Myringotomy – Myringotomy (surgical perforation of the tympanic membrane) permits drainage of the middle ear; it may be performed with or without placement of a tympanostomy tube. Myringotomy permits drainage of the mastoid if the aditus ad antrum is not blocked (figure 1) [1]. A wide-field large myringotomy should be performed in children with acute mastoid osteitis to ensure adequate drainage [1].
 
●Tympanostomy tube placement – Tympanostomy tubes permit drainage over a longer duration than myringotomy alone [1]. At most institutions, it is standard to place a tympanostomy tube when myringotomy is performed to ensure sustained drainage. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children" and "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes'.)
 
●Mastoidectomy – Mastoidectomy is the surgical removal of the mastoid cortical bone and underlying air cells. In simple mastoidectomy (also called cortical, complete, or canal-wall-up mastoidectomy), the posterior portion of the external auditory canal is preserved. In radical mastoidectomy (also called canal-wall-down mastoidectomy), the posterior portion of the external auditory canal is sacrificed.
 
Simple mastoidectomy is performed to clean out the mastoid infection, open the aditus ad antrum, and provide external drainage [1]. Radical mastoidectomy is performed only when there is no clinical response to simple mastoidectomy, as evidenced by continued otorrhea or pain [1].
 
Indications for mastoidectomy may include [1,6,27]:
 
•Clinical findings consistent with subperiosteal abscess, such as postauricular fluctuance or mass (regardless of computed tomography [CT] findings)
 
•Computed tomography evidence of coalescent mastoiditis (regardless of other clinical features)
 
•Other suppurative complications of acute mastoiditis (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications')
 
•Acute mastoiditis in a child with chronic suppurative otitis media or cholesteatoma
 
•Progression of postauricular swelling or fluctuance or persistence of fever, ear pain, or drainage despite parenteral antimicrobial therapy and tympanocentesis/myringotomy


==References==
==References==
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[[Category:Emergency mdicine]]
[[Category:Disease]]
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[[Category:Infectious disease]]
[[Category:Otolaryngology]]
[[Category:Surgery]]

Latest revision as of 22:39, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Overview

Different surgical procedures may be performed to treat mastoiditis. Myringotomy is surgical perforation of the tympanic membrane. It should be considered the primary treatment in all cases of infectious mastoiditis following otitis media, particularly when there is an unperforated tympanic membrane or inadequate drainage. Tympanocentesis should be performed in all mastoiditis patients to obtain middle ear fluid for culture and susceptibility testing. Myringotomy accompanied by the additional insertion of a tympanostomy tube is indicated in some cases, such as Eustachian tube dysfunction, suppurative complications requiring additional drainage, and when tympanic membrane must be repaired from Eustachian tube dysfunction. Definitive surgery is mastoidectomy, which is the surgical removal of the mastoid cortical bone and underlying air cells. Indications for mastoidectomy may include subperiosteal abscess such as postauricular fluctuance or mass, chronic suppurative otitis media or cholesteatoma, progression of postauricular swelling or fluctuance, fever, and other clinical findings or continuous drainage despite parenteral antimicrobial therapy and myringotomy.

Surgical procedures and indications

Different surgical procedures may be performed to treat mastoiditis:[1][2][3][4]

Incision and drainage of the mastoid abscess:

When fluctuation presents, drainage must be done immediately to achieve complete drainage of the pus.

Myringotomy

Myringotomy is the surgical perforation of the tympanic membrane.

Tympanocentesis

Tympanocentesis should be done in all mastoiditis patients to obtain middle ear fluid for culture and susceptibility testing.

Tympanostomy tube

Myringotomy accompanied by the additional insertion of a tympanostomy tube is indicated in the following:

Otorrhea is a possible complication of performing a myringotomy with a tympanostomy tube, affecting up to 17% of infected ears.[3]

Mastoidectomy

Definitive surgery is mastoidectomy, which is the surgical removal of the mastoid cortical bone and underlying air cells.

Methods

Indications for mastoidectomy may include:

The following video presents surgical procedures for mastoiditis:

{{#ev:youtube|jnonLwxW2Cg}}

References

  1. ↑ Zanetti D, Nassif N (2006). "Indications for surgery in acute mastoiditis and their complications in children". Int. J. Pediatr. Otorhinolaryngol. 70 (7): 1175–82. doi:10.1016/j.ijporl.2005.12.002. PMID 16413617.
  2. ↑ "Pediatric Guidelines: Head and Neck Infections - Mastoiditis | Infectious Diseases Management Program at UCSF".
  3. ↑ Lin HW, Shargorodsky J, Gopen Q (2010). "Clinical strategies for the management of acute mastoiditis in the pediatric population". Clin Pediatr (Phila). 49 (2): 110–5. doi:10.1177/0009922809344349. PMID 19734439.
  4. ↑ Pang LH, Barakate MS, Havas TE (2009). "Mastoiditis in a paediatric population: a review of 11 years experience in management". Int. J. Pediatr. Otorhinolaryngol. 73 (11): 1520–4. doi:10.1016/j.ijporl.2009.07.003. PMID 19758711.

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