SPECIAL ISSUE ARTICLE

Acute Mastoiditis Caused by

Streptococcus pneumoniae
Emily Obringer, MD; and Judy L. Chen, MD

ABSTRACT
Acute mastoiditis (AM) is a relatively rare complication of acute otitis media (AOM). The
most common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, and
Staphylococcus aureus. Pneumococcal vaccination and changes in antibiotic prescribing
recommendations for AOM may change the incidence of AM in the future. Diagnosis of
AM can be made based on clinical presentation, but computed tomography of the temporal bone with contrast should be considered if there is concern for complicated AM. Both
extracranial and intracranial complications of AM may occur. Previously, routine cortical
mastoidectomy was recommended for AM treatment, but new data suggest that a more
conservative treatment approach can be considered, including intravenous (IV) antibiotics
alone or IV antibiotics with myringotomy. [Pediatr Ann. 2016;45(5):e176-e179.]

Acute mastoiditis (AM) develops

as a complication of acute otitis media
(AOM) when infection spreads beyond
the middle ear and persists within the
mastoid bone. Children younger than
age 2 years are most commonly affected, although complications may
be seen more frequently in older age
groups.1,2 Given the proximity of the
mastoid bone to the central nervous
system, timely recognition and treatment of mastoiditis is critical.
To better understand the pathophysiology of mastoiditis and its complica-

tions, the anatomy of the middle ear and

mastoid is briefly reviewed (Figure 1).
A small medial connection unites the
mastoid air cells to the middle ear,
which is then drained by the eustachian
tube. Multiple structures, including the
sigmoid sinus, seventh cranial nerve,
carotid artery, and brain parenchyma,
lie adjacent to the mastoid air cells.
AOM causes inflammation and fluid
build-up within the middle ear. This
fluid frequently spreads to the mastoid
as well. In most cases, the inflammation
and fluid resolve with or without anti-

Emily Obringer, MD, is a Fellow, Pediatric Infectious Diseases, The University of Chicago Medicine
Comer Childrens Hospital. Judy L. Chen, MD, is a Pediatric Otolaryngologist-Head and Neck Surgeon
and a Clinical Educator, Department of Surgery, Section of Otolaryngology-Head & Neck Surgery, The
University of Chicago Medicine and Biological Sciences and NorthShore University HealthSystem.
Address correspondence to Emily Obringer, MD, Pediatric Infectious Diseases, The University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, IL 60637; email: Emily.Obringer@uchospitals.
edu.
Disclosure: The authors have no relevant financial relationships to disclose.
Acknowledgment: The authors would like to thank Colleen Nash, MD, MPH (The University of Chicago Medicine Comer Childrens Hospital) for critical review of the manuscript.
doi: 10.3928/00904481-20160328-01

e176

microbial treatment of AOM. However,

in rare instances AM can result from
persistent inflammation and infection.
The incidence of AM is relatively
rare, with approximately 1.6 episodes
per 100,000 person-years in the United
States.3 The number of episodes secondary to pneumococcal disease appears
to be in decline since the introduction
of population vaccination with the 13valent pneumococcal conjugate vaccine in 2010.4-6 In 2013, the American
Academy of Pediatrics proposed an
evidence-based clinical practice guideline that limited antibiotic use in AOM
based on age, severity, duration of
symptoms, and presence of otorrhea.7
The long-term influence of these recent
changes in antibiotic prescribing practices and pneumococcal vaccination on
the incidence of AM is yet to be determined.
ILLUSTRATIVE CASE
An 11-month-old fully vaccinated
infant presented to the otolaryngology
(ie, ears, nose, and throat [ENT]) clinic
with a 1-week history of left otitis media and persistent fever despite antimicrobial treatment. The patient was
seen by her pediatrician 1 week prior
to presentation and was initially treated
with cefdinir, but due to vomiting she
was switched to azithromycin after 3
days. Because of persistent fever, she
was then switched to amoxicillin/clavulanic acid 2 days later. Two days prior
to presentation at the ENT clinic, drainage was noted from the left ear and the
parents reported noticing protrusion of

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SPECIAL ISSUE ARTICLE

the auricle. In the ENT clinic, a review

of systems was significant for decreased
appetite and whimpering during sleep.
Of note, the patient had otitis media
(parents were unsure in which ear)
about 1 month prior that was treated
with amoxicillin/clavulanic acid.
The patients medical and surgical
histories were otherwise unremarkable,
with no developmental concerns. One of
her sisters had frequent ear infections.
The patient did not attend daycare, and
there were no smokers at home.
Her examination was notable for
symmetric facies except for the left
pinna, which was forward with postauricular edema without palpable
fluctuance. The right pinna and ear canal were normal. The right tympanic
membrane was opaque, erythematous,
and bulging. The left external auditory
canal was filled with copious purulent
material that was cleaned under the
microscope. The left tympanic membrane was thickened with erythema.
With a clinical presentation concerning
for acute mastoiditis, she was admitted
for intravenous (IV) antibiotics. Basic
laboratory studies noted a white blood
cell count of 18,200/mcL. She was administered IV ceftriaxone.
A computed tomography (CT) scan
of temporal bone with contrast was
performed to evaluate for potential
complications. This study confirmed a
left postauricular subperiosteal abscess
(Figure 2). After discussion with the
parents regarding treatment options,
the patient was taken to the operating
room for incision and drainage of the
abscess with myringotomy tube placement. She was continued on IV ceftriaxone and remained afebrile during
her hospitalization. Bacterial cultures
were taken intraoperatively and later
grew penicillin-sensitive Streptococcus
pneumoniae. Specific serotype testing
was not performed. She was discharged

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Figure 1. Anatomy of the mastoid. The mastoid sits between the middle ear and multiple important
structures, including the carotid artery, the seventh cranial nerve, and the sigmoid sinus. The eustachian
tube drains the middle ear, and a small connection called the aditus ad antrum unites the middle ear
and mastoid.

home on postoperative day 2 on oral

levofloxacin (due to her previous intolerance of other medications). She has
done well since discharge.
MICROBIOLOGY
Three bacteria cause the majority of
cases of AM disease: S. pneumoniae,
S. pyogenes, and Staphylococcus aureus.8 Isolation of a potential pathogen occurs in approximately 36% to
64% of episodes.6,9 Tympanocentesis
improves the rate of pathogen detection compared to ear canal swab and
decreases the likelihood of identifying
a contaminant.
S. pneumoniae is the most common
cause of pediatric AM.2,6,8,9 Prior to
the introduction of pneumococcal vaccination, serotype 19F accounted for
about 50% of all pneumococcal AM.10
In 2000, the heptavalent pneumococcal conjugate vaccine, which contained the predominant serotypes in
North America, including 19F, was introduced. This resulted in a near complete resolution of disease caused by
the 7 vaccine serotypes, but there was
minimal change in the overall incidence of pneumococcal AM due to rise
in episodes secondary to nonvaccine

pneumococcal serotypes, especially

serotype 19A.10 Early reports after the
2010 introduction of a 13-valent pneumococcal vaccine, which includes serotype 19A, suggest a significant decrease in pneumococcal AM.4-6
CLINICAL PRESENTATION
AM frequently presents with fever,
otalgia, retroauricular tenderness, edema, and erythema with later progression to proptosis of the auricle. Tympanic membranes have the appearance
of AOM and otorrhea can sometimes
be seen. A recent history of AOM may
or may not be present.1 Children older
than age 2 years may also present with
a longer duration of symptoms.2
Complications of AM can arise in
7% to 16% of cases.8 These may include
both extracranial and intracranial findings. Subperiosteal abscess formation is
the most common complication of AM
and occurs on average in 58% of cases.8
Other adjacent structures may also be
involved, such as the inner ear, neck
muscles, the facial nerve, and the cranial bones. Abscess formation within the
sternocleidomastoid muscle is a rare and
unique complication of mastoiditis; it is
termed a Bezold abscess.8 Facial nerve
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SPECIAL ISSUE ARTICLE

Figure 2. Subperiosteal abscess. Computed tomography of the temporal bone with contrast
showing left subperiosteal abscess measuring
2.15 cm in diameter.

palsy may result due to inflammation of

the nerve as it passes through the petrous
portion of the temporal bone. If the apex
of the petrous bone becomes infected,
Gradenigo syndrome results with unilateral periorbital pain due to trigeminal
nerve inflammation, sixth nerve palsy,
and otorrhea.8 Osteomyelitis may occur
in other cranial bones as well. Additionally, suppurative labyrinthitis can result
in hearing loss that may be permanent.
Infection may also spread to intracranial structures, including the sigmoid
sinus, meninges, dura, and brain parenchyma.11 Venous thrombosis occurs if
inflammation spreads medially, as only a
thin bone separates the mastoid from the
sigmoid sinus. Meningitis can also occur.
Abscesses can be found in the epidural
and subdural spaces, and the temporal
lobe and cerebellum are the most common sites of intraparenchymal disease.8
DIAGNOSIS
AM is a clinical diagnosis and imaging is not always needed. Uncomplicated
AM, AOM, and asymptomatic middle
ear effusions will look identical on CT
imaging, with all showing fluid in the
mastoid. With the renewed focus on reduction of radiation in the pediatric pope178

ulation, data suggest that CT imaging in

pediatric AM should be obtained in patients with signs or symptoms suggesting
possible complications, including neurologic signs, concern for cholesteatoma,
severe clinical presentation, failure to
improve or worsening with conservative
treatment, or suspected intracranial complication. Contrast-enhanced CT will allow for evaluation of abscess formation,
bony destruction, and extension into the
central nervous system. Magnetic resonance imaging may be better if venous
thrombosis is suspected. If meningeal
signs are present, a full set of laboratory
tests with cerebrospinal fluid sampling
is warranted after imaging. Plain radiographs are not indicated in the diagnostic
approach of AM.
When possible, middle ear fluid cultures should be obtained in cases of AM
to help direct antibiotic therapy. Cultures from tympanocentesis, abscess
drainage (when present), or surgical
specimens are the highest yielding. External ear canal samples frequently return contaminants, so results should be
interpreted carefully.
TREATMENT
Antibiotics
Prompt initiation of parenteral antibiotics that cover the major bacterial
pathogens for AM is recommended. A
variety of empiric antimicrobial regimens can be used. Some experts recommend vancomycin alone; however, past
studies indicate that ceftriaxone alone
or a combination of beta-lactam/betalactamase inhibitor agents are the most
commonly used regimens.8,12,13 Recent
antimicrobial use, immunization status,
and knowledge of local resistance patterns can help direct initial choice of
therapy. If culture results are available,
antibiotics should be tailored accordingly. Transition to oral antibiotics can occur once clinical improvement is noted.

A 4-week antibiotic course, including

initial IV therapy, is typical.8
Surgical Management
In the past, surgical treatment of
AM consisted of routine cortical mastoidectomy. However, more recently
conservative measures have been successfully used, including treatment with
IV antibiotics alone, or IV antibiotics
with myringotomy with or without tube
placement.12,14,15 Geva et al.12 and Groth
et al.2 found that myringotomy may be
required more frequently for younger
children. Older patients, who may present with a longer duration of symptoms
prior to treatment, have a greater need
for mastoidectomy.2
Similarly, subperiosteal abscess has
historically required a mastoidectomy,
but incision and drainage or needle aspiration can now be considered.13,16 Groth
et al.2 found that younger patients are
more likely to have a subperiosteal abscess drained than older patients.
If a more conservative approach is
taken, the patient should be monitored
for signs and symptoms of clinical worsening. If there is concern for treatment
failure, additional imaging and mastoidectomy should be considered.
SUMMARY
Acute mastoiditis remains a rare
complication of acute otitis media. Diagnosis can be made on a clinical basis;
however, a CT scan of the temporal bone
with contrast is recommended to evaluate for complications. Conservative
management with IV antibiotics alone
or IV antibiotics with myringotomy
with or without tube placement has been
shown to be effective. Transition to oral
antibiotics can occur when the patient
has achieved clinical improvement.
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