Acute Mastoiditis



A 2 yo presents to the clinic with R sided ear pain, discharge and fever for the last 2-3days. When she woke up this morning her mother noticed that the skin around the R ear had turned red, with swelling behind the R ear as though the ear had been pushed forward. 
She frequently gets ear infection and her last ear infection was last month when she was placed on amoxicillin for 10days.
Mom denies any changes in her mental status, she has a poor appetite but had been drinking well and has had a good urine output.
On taking a social history mom mentions that dad smokes inside the house and sometimes she puts her to sleep with a bottle of milk in her mouth.

1. What is your diagnosis?
2. Is imaging warranted in this scenario?
3. Why is the social history important in this case?
4. What is your choice of antibiotics ?


Definition :
- infection of the mastoid air cells
- clinically characterized by a) protrusion of the pinna b) erythema/ tenderness over the mastoid process
- 50% are not preceded by an acute otitis media infection

Epidemiology :
- age range 6-24months
- M:F 2:1
- unusual to see it in very young due to incomplete pneumatization of the mastoid air cells
- also unusual to see nowadays given that there is pretty aggressive treatment of ear infections with antibiotics

Prevention :
- early Rx of AOM
- avoid factors which predispose to otitis media such as smoking or bottle feeding
the famous smoking indonesian baby , smokes 40 cigarettes/ day

Bottle feeding, always prop up, never let baby to sleep with bottle in mouth


Etiology :
50% may present without any preceding evidence of otitis media
- strep pneumo, staph aureus.
- chronic mastoiditis : staph aureus, mycobacterium TB. anaerobic bacteria, enteric bacteria, pseudomonas aeroginosa

Clinical features :
- fever, otalgia, otorrhea
- abscess formation
- labrynthitis - tinnitus, vertigo, nystagmus, loss of balance
- extra/ intra cranial complications - stiff neck, headache, seizures, visual changes
 - o/e swelling and redness behind the ear, pinna may be raised and protruding outwards
- palpable abscess
- ear pain, discharge, hearing loss

Imaging :
- If suspect intra-cranial complications get head CT / MRI
- XR helpful is shows destruction but there may be false positives

http://oghalailab.stanford.edu/images/tngallery/acute%20mastoiditis%20-%20CT%20scan.jpg

Treatment :
1. If pus behind the TM, consult ENT to perform a myringotomy
2. Will require treatment with IV antibiotics - consider broad coverage like IV oxacillin / gentamicin/ cefotaxime
3. Surgical intervention required if signs of Bezold's abscess, coalescent mastoiditis, sinus venous thrombosis, facial nerve palsy, intracranial abscess, persistent symptoms despite adequate antibiotic coverage,

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