Mastoiditis surgery

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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:

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.

• It should be considered a primary treatment in all cases of infectious mastoiditis when there is an unperforated tympanic membrane or inadequate drainage.
• Myringotomy may be done with or without tympanostomy tube placement.

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:

• Eustachian tube dysfunction
• Suppurative complications requiring additional drainage via the tympanostomy tube
• Necessity to repair the tympanic membrane from Eustachian tube dysfunction

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

• 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

The following video presents surgical procedures for mastoiditis:

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