Mastoiditis surgery

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

Surgery

Surgical treatment in mastoiditis should be done in below conditions

• Intracranial complications.
• Cholesteatoma.
• Not achieving adequate response after 24 to 48 hours of starting treatment
• 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:

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.

b.

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.

a.

Definitive surgery:

•

If cholesteatoma is present, an open mastoidectomy should be performed.

•

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.

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.

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