This serious inflammation of the base of the temporal bone – which is often the consequence of poorly treated otitis – requires emergency treatment. What are its symptoms? How to make the diagnosis? What are the treatments ? The answers from Dr Raphaël Hadjedj, ENT surgeon in Paris.
Definition: What is mastoiditis?
Mastoiditis is an acute infection of the prominent bone behind the ear called the mastoid. This bone has a porous structure and contains air cells called mastoid cells, which are interconnected and part of the air system of the middle ear. The mastoid is anatomically linked to the middle ear, and also associated with the tympanic cavity.
“Mastoiditis is most often the complication of acute otitis media, not or poorly treated.” indicates Dr Hadjedj. It is a rare condition, which occurs in 2 to 4 people in 100,000 each year. It mainly affects children and is rarer in adults.
“Its incidence has decreased considerably since the advent of antibiotics in the early 1940s. In the 1930s, one in ten otitis infections developed into mastoiditis.” underlines the ENT doctor.
Pain behind the ear, swelling: What are the symptoms and clinical signs of mastoiditis?
The symptoms of mastoiditis are first of all those of acute otitis media, namely a change in general condition, fever, pain and sometimes discharge from the ear. “Then, the characteristic symptoms of mastoiditis are: swelling of the retroauricular groove (i.e. the natural fold located behind the ear) which causes the pinna to detach from the ear (protruding ear), and a bulging eardrum with sometimes a discharge of pus” describes the specialist.
In rare cases, the infection spreads medially, towards the front of the temporomandibular joint, or resulting in a Bezold’s abscess when this spreads downward. The latter is characterized by the presence of pus extended beyond the mastoid, which can spread into the neck muscles and cause intense pain behind the ear, swelling in the neck, redness of the skin, fever and difficulty moving the neck.
What are the causes of mastoiditis?
Mastoiditis is almost always the consequence of acute otitis media, which has either not been treated or has been poorly treated. “If the antibiotic was ineffective on the germ, or the treatment was stopped early, the otitis can degenerate and cause mastoiditis.” summarizes Dr Hadjedj. Most mastoiditis is therefore a complication of bacterial otitis, in which the bacteria involved is generally either Streptococcus pneumoniae either Haemophilus influenzae.
Is mastoiditis contagious?
Mastoiditis is an inflammation resulting from a poorly treated bacterial infection. “Neither mastoiditis itself, nor bacterial otitis of which it is a complication, are contagious.” reassures the ENT surgeon.
Scanner, MRI: How to diagnose mastoiditis?
In the majority of cases, the diagnosis of mastoiditis is clinical, and involves questioning and examining the patient by an ENT doctor using an otoscope. “We observe a picture of acute otitis media with swelling behind the ear which detaches the pinna” describes Dr. Hadjed.
Although this characteristic clinical picture may be sufficient to confirm the diagnosis, a CT scan of the skull is generally suggested, in order to visualize the abscess and look for other complications of acute otitis media, such as meningitis or empyema – to know is collection of pus in the extradural space.
“The use of an MRI can be discussed, in case of doubt about another complication, such as lateral sinus thrombophlebitis for example.” adds the specialist. Blood tests can be done to confirm the presence of an infection and help determine the bacteria responsible.
Treatment and management: How to treat mastoiditis?
Mastoiditis is a medical emergency that in the majority of cases requires hospitalization. “It begins with the implementation of an intravenous antibiotic treatment, most often from the C3G family, adapted to the germ in question.” indicates Dr Hadjedj. The choice of antibiotic depends on the type of bacteria identified, if possible, from a blood test or pus discharge.
In case of abscess, a puncture of the abscess with paracentesis is performed. “This is a short operation performed in the operating room, usually under general anesthesia depending on the severity of the abscess.” explains the surgeon. In certain cases, a transtympanic aerator (yoyo) is placed in order to drain the pus behind the eardrum.
24/48 hour monitoring is then carried out: if the evolution is not favorable, surgery may be necessary. “The operation is a mastoidectomy, which involves milling the mastoid bone to open the mastoid cells and empty them of the pus they contain.” explains Dr Hadjedj. Surgery is immediately indicated in the event of an intracerebral complication, which can notably manifest itself as facial paralysis. This operation requires 4 to 7 days of hospitalization in children.
What complications?
Mastoiditis can become complicated in several ways if it is not diagnosed and treated promptly.
- Permanent hearing loss: Untreated mastoiditis can damage structures in the ear, leading to permanent hearing loss.
- A cholesteatoma : Recurrent or chronic mastoiditis can promote the formation of cholesteatoma, an abnormal growth of epithelial cells in the middle ear and mastoid.
- Facial paralysis : In severe cases, the infection can affect the facial nerve, leading to temporary or permanent facial paralysis.
- Labyrinthitis : The infection can spread to the inner ear, causing inflammation known as labyrinthitis, which can lead to dizziness and balance problems.
- A spread of infection : Infection of the mastoid can spread to other parts of the skull, which can lead to serious complications, such as meningitis, brain abscess or sigmoid sinus thrombophlebitis, up to and including death of the patient.
“Mastoiditis is a medical emergency that requires very rapid treatment.” insists Dr Hadjedj.