Mastoiditis

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IntroductionDevelops as a complication of acute suppurative otitis media, mostly in children. Follows acute otitis media (untreated or inadequately treated), or due to particularly virulent organisms. Infection spreads from the tympanum posteriorly into the mastoid antrum and air cells. Colliquative necrosis of the air cells and suppuration in the mastoid bone follows. A subperiosteal abscess forms behind the ear in a child with a discharging ear.

Clinical features

  • Fever
  • Pain behind the ear
  • Mucopurulent ear discharge
  • Progressive inflammatory swelling over the mastoid region
  • Swelling is tender and fluctuant

Differential diagnosis

  • Suppurating post-aural lymphadenitis from otitis externa

Complications

  • Spread of infection into cranial cavity with:
  • Extradural abscess
  • Meningitis
  • Brain abscess
  • Lateral sinus thrombophlebitis

Investigations

  • Ear swab for microscopy, culture, culture, and sensitivity
  • Radiographs of the mastoid
  • CT Scan of petromastoid
  • MRI of the petromastoid

Treatment goals

  • Control and eradicate infection
  • Prevent more serious complications

Non-drug treatment

  • Cortical mastoidectomy to open the mastoid
  • Exenterate the infected air cells and drain the mastoid

Drug treatment

  • Antibiotics: Large doses of parenteral antibiotics
    • Amoxicillin
      • Adult: 500 mg -1 g intravenously 6-8 hourly for 7 days
      • Child: 50 - 100 mg/kg intravenously 6 - 8 hourly in divided doses daily for 7 days
    • Ceftriaxone
      • Adult: 1 g 12 hourly intravenously for 7 days
      • Child:
        • 13 years and above: 1 g 12 hourly by intravenous infusion over 60 minutes
        • 1 month - 12 years (body weight under 50 kg) 50 mg/kg once daily, up to 80 mg/kg in severe infections
        • Neonates: 20 -50 mg/kg once daily, by deep intramuscular injection or by intravenous injection over 2 - 4 minutes, or by intravenous infusion
  • Analgesics
    • Paracetamol
      • Adult: 500 mg -1 g orally 4 - 6 hourly (to a maximum of 4 g daily) for 5 - 7 days
      • Child
        • over 50 kg: same as adult dosing
        • 6 - 12 years: 250 - 500 mg;
        • 3 months - 5 years:125 - 250 mg taken orally 4 - 6 hourly for 5 - 7 days

Supportive measures

  • Bed rest: in-patient care
  • Intravenous infusion as appropriate

Prevention

  • Adequate and timely treatment of acute otitis media