Makindo Medical Notes

Related Subjects: |Assessing Hearing Loss |Benign Paroxysmal Positional Vertigo (BPPV) |Cholesteatoma |Epistaxis (Nosebleeds) |Acute Mastoiditis |Nasal polyps |Acute Sinusitis |Sudden Sensorineural Hearing loss (SNHL) |Causes of Vertigo

Acute mastoiditis requires prompt and effective treatment to prevent severe infratemporal and potentially life-threatening intracranial complications. A rare but serious complication is otitic hydrocephalus, which presents with symptoms of raised intracranial pressure, including headache, papilloedema, and abducens nerve palsy.

About

• Acute mastoiditis is a complication of Acute Otitis Media (AOM), involving infection and inflammation of the mastoid air cells in the skull.
• Can occur in both adults and children, though more common in children.
• Typically follows untreated or inadequately treated middle ear infections.

Aetiology

• Results from the spread of infection from the middle ear to the mastoid air cells, usually by bacteria involved in otitis media.
• Common causative organisms include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
• Spreading intracranial infection is a serious concern due to proximity to meninges and other cranial structures.

Clinical Presentation

• Tenderness, erythema, and swelling over the mastoid process.
• The ear may be displaced forwards due to swelling behind it.
• Narrowing of the external auditory canal due to inflammation and swelling.
• The tympanic membrane may appear red and bulging if there is active middle ear infection.
• Signs of systemic infection such as fever and malaise.
• In severe cases, any signs of reduced Glasgow Coma Scale (GCS) or focal neurological deficits require urgent escalation as they may indicate intracranial spread.

Investigations

• FBC, U&E, CRP to assess the inflammatory response and baseline renal function.
• Blood cultures if sepsis is suspected.
• Ear swab if there is discharge to identify causative organism and sensitivities.
• CT or MRI of the temporal bones to detect complications such as abscess formation, bone destruction, or venous sinus thrombosis.

Complications

• Meningitis: infection spreads to the meninges, requiring immediate treatment.
• Brain abscess: formation of an abscess in the brain, which can be life-threatening.
• Lateral venous sinus thrombosis: a potentially fatal complication that occurs when infection spreads to the dural venous sinuses.
• Facial nerve palsy: infection impacts the facial nerve as it passes through the temporal bone.

Management

• IV antibiotics are required, often Co-Amoxiclav or Cefuroxime, guided by local antibiotic protocols to cover typical pathogens.
• Urgent ENT consultation for potential surgical intervention, including:
  • Incision and drainage if abscess formation is suspected.
  • Myringotomy: surgical incision of the tympanic membrane to relieve pressure and drain infected material.
  • Grommet insertion to ventilate the middle ear and prevent recurrent infection.
  • Cortical mastoidectomy to remove infected mastoid air cells in severe or unresponsive cases.

Prognosis and Follow-Up

• With early and effective treatment, prognosis is generally good.
• Close follow-up is essential to monitor for recurrent infection or complications, particularly in cases where surgery was required.
• Patients should be educated on early signs of otitis media to seek prompt treatment and avoid progression to mastoiditis.

References

• Acute Mastoiditis Management