Mastoiditis is an infection of the mastoid air cells that can develop as a complication of acute otitis media. It can present as acute or chronic and have various classifications. While now rare due to antibiotics, potential complications include intratemporal extensions into nearby structures or intracranial extensions through direct bone erosion. Management involves antibiotics, with mastoidectomy sometimes needed for severe or unimproving cases to prevent serious complications. Complications range from local abscesses to epidural abscesses, venous sinus thrombosis, and even more serious intracranial infections if not properly treated.

1. Complications of mastoiditis
Sarita pandey

2. introduction
• Mastoid process is an inferior extension of the petrous temporal bone
• Provides a structural function as an anchor point for large muscles of
the neck
• Contains multiple air cells that develop from single main cavity
(antrum)
• In X section is has a honey comb appearance

3. Mastoid process • Sternocleidomastoid
• Splenius capitus
• Posterior belly of digastric
• Longissimus capitus muscle

4. introduction
• Tympanic cavity of middle ear is in communication with the mastoid
antrum via aditus
• Mastoid air cells are related superiorly to middle cranial fossa and
posteriorly to posterior cranial fossa
• Acute mastoiditis is serious complication of acute OM
• Mastoiditis occurs when supperative infection extends from middle
ear affected by OM to mastoid air cells
• Once mastoiditis sets in it in it self has more complications.

5. Classification of mastoiditis
• Classic or acute Mastoiditis – complication of AOM
• Chronic, latent or masked mastoiditis presents in chronic or
subclinical fashion
• Associated with CSOM or Cholesteatoma

6. Epidemiology
• Acute mastoiditis prior to advent of antibiotics was common
• Developed in 5 – 10% of children with AOM
• Mortality rate 2/100000 children
• Currently 0.12/1000 child per year
• Mortality rate < 0.01/100000
• Estimated that In every 50000 child with AOM 1 child develops
mastoiditis

7. Acute mastoiditis
• Much more common in young children with peak incidence at 6 – 13
months
• Immunocompromised patients more prone to mastoiditis
• Children/adults with intellectual impairment or communication
difficulties thought to be susceptible to mastoiditis
• Pre-existence of cholesteatoma is a known risk factor

8. Infecting organisms
• Streptococcus pneumonia 25% prevalence
• H Influenza
• S. pyognes
• Staphyloccus spp
• Pseudomonas aeruginosa (becoming more common as widespread use of
Abs increases)
• Moraxella Catarrahalis
• Gm neg bact
• Mycobacteria
• Aspergillus & other fungi (immunocompromised patients)

9. Presentation - acute mastoiditis
• History of acute or recurrent episodes of OM
• Otalgia or pain behind ear
• Fever
• Swelling, redness or boggy, tender mass post auricular region
• Irritable infant, with feeding difficulties
• Forward protrusion of external ear, may have fluctuance in the mass
• Ear discharge/ middle ear effusion
•

10. Presentation – chronic mastoiditis
• Presents in a subtle or subclinical fashion after an
episode of AOM
• Recurrent bouts of otalgia and retro- aural pain
• Recurrent headaches
• Febrile episodes
• TM may appear infected or postero-superior retraction/
perforation with pus
• May be no external evidence of peri mastoid
inflammation

11. Investigations:
• FBC – leucocytosis
• Elevated ESR
• Blood cultures
• Pus swab of any pus/ fluid in middle ear
• CT gold standard
• IF intracranial spread suspected LP
• Audiogram once pain under control.

12. Management
• Manage as an IN patient
• To prevent likelihood of complications
• High dose broad spectrum iv antibiotics for at least 48 hours
• Oral antibiotics may be used after 48 hours if clinically improving
• Anti pyretic
• Myringotomy plus grommet as therapeutic and diagnostic procedure

13. Surgical management
• Mastoidectomy
• Mastoid osteitis
• Co –existing cholesteatoma
• Limited improvement after ivi meds

14. Complications of mastoiditis
• Rare due to prompt antibiotic treatment, however with emergence of
resistant organisms – may be higher in future
• Clinically divided into:
• Intratemporal
• Intracranial
• Systemic
• cervical

15. Extension of infection…
• Direct extension through the de-mineralized bone seen in
cholesteatoma
• Haematogenous spread via the veins, through bone and dura to the
venous sinuses.
• Through round or oval window into the auditory meatus on the
vestibular aqueducts
• Dehiscence of bony covering over the jugular bulb or the tegmen
tympani
• Neoplastic or accidental bony erosion
• Through surgical defects in post stapedectomy surgery.

16. Intra - temporal
• Coalescent Mastoiditis
• When mastoid region inflammation cannot be arrested
• Suppuration under pressure causes local acidosis and osseous decalcification,
ischaemia and osteoclastic dissolution of the pneumatic cell walls
• These cells can coalesce into larger cavities filled with purulent exudates and
granulations
• Resulting in empyema & coalescent mastoiditis
• Antonelli et al – concluded that erosion of the cortical plate overlying
the sigmoid sinus was the most sensitive and specific CT scan finding
for distinguishing coalescent vs incipient acute mastoiditis

17. Coalescent mastoiditis
• Spread of the inflammatory debris anteriorly to middle ear via aditus
ad antrum can result in spontaneous resolution if the TM is
perforated
• Infection may spread laterally and produce sub periosteal abscess
• May spread medially to petrous air cells, causing petrositis
• Coalescent mastoiditis is diagnosed when CT demonstrates erosion of
mastoid septa or mastoid walls

18. Coalescent mastoiditis
• Latent mastoiditis (subclinical and often “masked”)
• Indolent temporal bone infection with few clinical symptoms
• Often owing to previous usage of broad spectrum antibiotic to treat Middle
ear disease
• TM is intact and middle ear shows no abnormalities at otoscopy
• Disease progresses silently until an intracranial complication such as venous
Dural thrombosis occurs
• CT diagnostic, demonstrates the temporal bone disease and the intracranial
complication

19. Sub periosteal abscess
• Decalcification of the outer mastoid cortical bone results in abscess
that can extend towards
• Ext auditory canal
• Spread along the zygomatic bone
• Post auricular region

20. Perisinus abscess
• When osteolysis occurs in the
internal mastoid cortex
• Direct apposition of the
inflammatory debris to dura
over the sigmoid sinus
• Resulting in formation of
perisinus and epidural abscess

21. Petrositis
• Petrositis or petrous apicitis – rare complication that theoretically
occurs only in individuals with pneumatized petrous apex
• Patient present with CN VI palsy, deep facial pain and ipsilateral
otorrhoea ( Gradenigo syndrome)
• Facial pain due to focal meningitis over the petrous apex with
irritation of the gasserian ganglion in the Meckel cave
• Abducens nerve involvement occurs at its course through the Dorello
canal
• CT demonstrates erosive changes of the petrous apex with abn
enhancement of adjacent meningitis

23. Other intratemporal complications
• Labyrinthitis
• CN VII palsy
• SNHL
• More common in chronic otitis media with cholesteatoma
• Infection can spread into the labyrinth via the round or oval window
or by direct invasion of the bony labyrinth
• May result in suppurative labyrinthitis
• Suspect when patient with infected ear develops sudden vertigo,
nystagmus and hearing loss

24. Intracranial complications
• Epidural abscess
• Most common intracranial complication
• Results from spread by contiguity following bone destruction in coalescent
mastoiditis
• Can occur in middle cranial fossa
• Posterior cranial fossa is more common
• Due to osseous destruction in the Trautmann triangle over the
sigmoid sinus plate or in the posterior cortex of petrous pyramid
• CT is mandatory for Diagnosis

25. Dural venous thrombophlebitis
• As an result form extradural abscess
• Sigmoid sinus thrombosis as a protective mechanism in attempt to localise
infection
• Thrombus may cause propagation to jugular vein, to other sinuses
• Through emissary veins to subcutaneous tissue
• Diagnosis may be difficult to make on basis of clinical picture alone
• May be completely asymptomatic
• Present as sign of toxaemia, intracranial hpt or hydrocephalus
• Mastoidectomy with surgical exposure of the dura and removal of the
granulation tissue
• Use of anticoagulation and ligation of IJV are controversial

26. Dural venous phlebothrombosis

27. Subdural empyema
• Several veins and veinules in middle normally communicate through
intact bone and dura with vessels in subarachnoid space and brain
parenchyma
• Spread of infection and microorganisms through these veins reach
subdural and subarachnoid space
• Develops in interhemispheric fissure and along the tentorium
cerebelli
• CT = widening of the extra cerebral space with compression of
adjacent sulci
• Loculations within collection common

28. subdural

29. Other intracranial complications
• Meningitis
• Hydrocephalus
• Encephalitis
• Parenchymal cerebral or cerebellar abscesses
• Occurrence in young children by haematogenous dissemination
• Invasive organisms such as H. influenza type B more common
• Neurologic sequalae of MR or SNHL

30. Carotid artery involvement
• Exceptional in the AB era
• Potential life threatening complication
• Internal carotid more likely to be involved
• Due to large no of lymph nodes adherent to ICA
• Spread of infxn from adjacent IJV most likely to be mechanism of
infection

31. • Protracted clinical course
• Recurrent haemorrhage from Throat, nose or ear
• Horner syndrome
• Diagnosis often made at an advanced stage, when patient develops
haemorrhage, pseudo aneurysm or hemiplegia
• MR angiography most helpful and can show features of carotid artery
spasm
• Worst scenario – carotid occlusion /rupture

32. Other Head &Neck complications
• Bezold abscess
• along the medial aspect of mastoid tip up to sheath of SCN
• Citelli’s abscess
• along posterior belly of digastric
• Luc’s abscess
• along the posterior wall of the external auditory canal
• Para pharyngeal and retropharyngeal abscess
• Case in literature due to spread of the infection along the EU tube and
spreading into the Retropharyngeal and Para pharyngeal spaces

33. Bezold Abscess
• Occurs as a result of osteolysis at the mastoid tip
• The pus/debris may extend inferiorly into the soft tissue of the neck
and form an abscess
• Aeration of mastoid bone with resulting thinning of osseous walls is
believed to be predisposing factor for bezold abscess
• Incomplete mastoid pneumatisation in infancy and early childhood is
responsible for rare appearance in children
• Very few cases reported in children under 5 years of age

34. Diagnosis??