Now let us assume we have a severe acute infection and no antibiotic treatment. This scenario is extremely rare these days. The suppuration in the middle ear and adjacent mastoid cavity may continue. There is usually
Fig. 5.4 Mastoiditis with subperiosteal abscess.
(Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997)
little pain because the middle ear continues to decompress through the draining perforation.
Two or three weeks may elapse before the fourth stage of mastoiditis develops. Pockets of pus continue to brew in the middle ear and adjacent mastoid cavity, breaking down the bony septal walls. Physical findings may now include tenderness over the mastoid process, sagging of the posterior external canal wall, persistent drainage through a "nipple" in the TM, and possibly, a subperiostial abscess over the mastoid, bulging behind the ear (Fig. 5.4). This bulge usually causes the auricle to protrude abnormally.
This condition is classically termed acute coalescent mastoiditis and can be demonstrated radiographically. Incidentally, with any middle ear fluid, even sterile and serous, the mastoid air cells will contain fluid that shows on routine mastoid X-rays or CT scan. Radiologists sometimes over-read any opacification of the mastoid cells as "mastoiditis." The difference with the true disease is the apparent breakdown of bony air cell septa, or "coalescence."
Aggressive treatment is required, with hospitalization and broad-spectrum IV antibiotics, based on a culture of the secretions. Surgical mastoidectomy should be performed. If these measures are not taken, or are unsuccessful, a fifth stage of complication may occur, due to spread of infection beyond the mastoid. Here, the patient may have complications
Retraction of the Tympanic Membrane 61
including meningitis, epidural or brain abscess, and sigmoid sinus thrombosis, all potentially fatal. Look for severe headache, high fever, obtundation, and possibly a stiff neck. One rare complication is Gradenigo's syndrome, caused by localized mastoiditis deep in the cells of the petrous apex of the temporal bone. It is symptomatic with persistent ear discharge, deep eye pain, and diplopia due to paresis of cranial nerve VI.
Rarely, unoperated cases of acute coalescent mastoiditis may resolve with aggressive antibiotics and no surgery, but a sequestrum of chronic osteomyelitis may form in the mastoid cavity. This will cause ongoing purulent drainage and chronic mastoiditis, which will also eventually require surgery.
Inflammatory postauricular adenopathy deserves mention here. One or more lymph nodes reside under the skin behind the auricle overlying the mastoid bone. These drain adjacent areas of the scalp and may become enlarged for any reason, sometimes with tenderness. They may be mistaken for mastoiditis; the important distinguishing point is that no infection is seen in the middle ear, and mastoid X-rays or CT (if done) should be clear.
An individual who has rapid-onset earache following a respiratory infection, and a red or bulging drum, probably has acute otitis media! Antibiotic choices are discussed in the text. The extremely rare complication of acute mastoiditis may be recognized by persistent drainage through a nipple-like perforation in the drum for several weeks following an untreated acute infection, with mastoid swelling and tenderness. The primary clinician should follow up on a treated middle ear infection until it is resolved. A CT scan and ENT consultation should be obtained if mastoiditis is suspected, or if middle ear fluid persists.
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