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Mastoiditis

Definition all inflammatory processes of the mastoid air cells of the temporal bone. virtually every child or adult with acute otitis media (AOM) or chronic middle ear inflammatory disease has mastoiditis Classification a. Acute Mastoiditis Acute mastoiditis is associated with AOM Infection spreads beyond the mucosa of the middle ear cleft directly by bone erosion through the cortex or indirectly via the emissary vein of the mastoid develop osteitis within the mastoid air-cell system or periosteitis of the mastoid process,. b. Chronic mastoiditis Most commonly associated with chronic suppurative otitis media and particularly with cholesteatoma formation Cholesteatomas are benign aggregates of squamous epithelium that can grow and alter normal structure and function of surrounding soft tissue and bone. This destructive process is accelerated in the presence of active infection by the secretion of osteolytic enzymes by the epithelial tissue. Mastoiditis progresses in the following 5 stages and may be arrested at any point: 1. 2. 3. 4. 5. Hyperemia of the mucosal lining of the mastoid air cells Transudation and exudation of fluid and/or pus within the cells Necrosis of bone by loss of vascularity of the septa Cell wall loss with coalescence into abscess cavities Extension of the inflammatory process to contiguous areas

Etiology host factors (mucosal immunology, temporal bone anatomy, systemic immunity) microbial factors (protective coating, ability to penetrate local tissue or vessel) Host factors Most children <2yo (immune system is relatively immature) + have history of otitis media Host anatomical factors o Mastoid part of temporal bone and a narrow outpouching of the posterior epitympanum Pneumatization occurs shortly after birth.

o Mastoid air cells are created by invasion of epithelium-lined sacs between spicules of new bone and by degeneration and redifferentiation of existing bone marrow spaces. o The antrum, as with the mastoid air cells lined with respiratory epithelium infection swelling will blockage the antrum inhibiting drainage and precluding reaeration from the middle-ear side entraps infection within the air cells by.

o Persistent acute infection within mastoid cavity osteitis destroys bony trabeculae that form the mastoid cells coalescent mastoiditis (empyema of the temporal bone that, unless its progress is arrested, drains either through the natural antrum to give spontaneous resolution or creates further complication by draining unnaturally to the mastoid surface, petrous apex, or intracranial spaces) o Other temporal bone structures or nearby structures, such as the facial nerve, labyrinth, and venous sinuses, may become involved. Complications Hearing loss Facial nerve palsy Cranial nerve involvement Osteomyelitis Petrositis Labyrinthitis Gradenigo syndrome - Otitis media, retro-orbital pain, and abducens palsy Intracranial extension - Meningitis, cerebral abscess, epidural abscess, subdural empyema Sigmoid sinus thrombosis Abscess formation - Citelli abscess (extension to occipital bone, calvaria), subperiosteal abscess (abscess between the periosteum and mastoid bone, resulting in the typical appearance of a protruding ear; see the image below), and Bezold's abscess (abscess of soft tissues that track along the sternomastoid sheath; Bezold abscesses are very rare complications and are usually found only in adults with a well-pneumatized mastoid tip)

Presentation >80% have no history of recurrent otitis media Persistent otorrhea >3 weeks most consistent sign The patients fever may be high and unrelenting in acute mastoiditis, but this may be related to the associated acute otitis media (AOM). Pain localized deep in or behind the ear + worse at night. Persistence of pain is a warning sign of mastoid disease. Hearing loss is common with all processes that involve the middle ear cleft. In adults, the most common symptoms of mastoiditis otalgia, otorrhea, and hearing loss, and the physical signs of mastoiditis (ie, swelling, erythema, tenderness of the retroauricular region) Physical Examination Frequent symptoms include mastoid area erythema, proptosis of the auricle, and fever. Tenderness and inflammation over mastoid process most consistent sign Periosteal thickening Subperiosteal abscess displaces auricle laterally and obliterates the postauricular skin crease

Workup a. Complete blood count b. Audiometry must be performed after convalescence from the acute phase and with children who have chronic mastoiditis c. Tympanocentesis aspiration of middle ear fluid send fluid for cultures, Gram stain, and acid-fast stain. d. Myringotomy small incision of the tympanum to express fluid from the middle ear in chronic or recurrent otitis media relieves discomfort associated with pressure from AOM e. Imaging Plain radiography (the Schuller view) demonstrate clouding of the air cells with bone destruction in ASM. In the vast majority of cases, radiographs suffice to establish the diagnosis but lack the sensitivity to differentiate the stages of the disease and fail to show the petrous apex

in any great detail.

CT Scan the standard for evaluation of mastoiditis, with published sensitivities ranging from 87-100% Findings: o Opacification of the mastoid air cells and middle ear by inflammatory swelling of mucosa and by collection of fluid o Loss of sharpness or visibility of mastoid cell walls due to demineralization, atrophy, or necrosis of bony septa o Haziness or distortion of the mastoid outline, possibly with visible defects of the tegmen or mastoid cortex o Enhancement of areas of abscess formation o Elevation of the periosteum of the mastoid process or posterior cranial fossa o Osteoblastic activity in chronic mastoiditis

MRI not typically the radiographic study of choice helpful in showing inflammatory processes and differentiating certain tumors standard for evaluation of contiguous soft tissue, particularly

the intracranial structures. MRI is the preferred imaging modality for the potential complications of ASM (ie, abscess formation, sinus thrombosis). Treatment a. Antibiotics tandard antibiotic therapy is administered for AOM, and resolution is anticipated within 2 weeks. b. Surgery myringotomy/tympanocentesis, tympanostomy tube placement, and mastoidectomy Indications for surgery : acute suppurative otitis media that fail to respond to appropriate antibiotic therapy and progress to coalescent mastoiditis. a. Myringotomy/tympanocentesis used to obtain specimens and to relieve discomfort from acute otitis media (AOM). These openings usually heal within a few days b. Tympanostomy tube for drainage of entrapped pus and aeration of the middle ear and mastoid. allow topical antimicrobials to enter the middle ear space maintains the opening in the tympanic membrane provides access to the middle ear and mastoid for antibiotic/steroid drops and for drainage without concern for patency of the Eustachian tube. c. Mastoidectomy Surgical removal of infected mastoid air cells This procedure involves opening the mastoid air cells by making a postauricular incision and entering the mastoid by removing the mastoid cortex using a drill Indications for mastoidectomy for advanced disease, such as mastoid osteitis, intracranial extension, abscess formation, when cholesteatoma is involved, or if little improvement occurs after 24-48 hours of intravenous antibiotics.

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