Acute mastoiditis is a suppurative infection of the mastoid air cells, most commonly arising as a complication of acute otitis media (AOM). It predominantly affects children (mean age 2–4 years) but can occur in adults. It carries significant morbidity due to intracranial and extracranial complications, with intracranial complications occurring in 6.5–13.7% of cases. [1-3] Peak incidence occurs during winter months. [4]
1. History
- Preceding AOM: Duration, treatment received, antibiotic course and compliance, response to therapy
- Ear symptoms: Otalgia (often worsening or recurrent after initial AOM treatment), otorrhea, hearing loss, aural fullness
- Systemic symptoms: Fever, malaise, irritability (especially in young children), poor feeding
- Timing: Symptoms typically develop during or within 2 weeks of AOM; suspect in patients who fail antibiotic treatment for AOM [1]
- Progression: Worsening despite antibiotics is a key feature
- Important negatives: Headache, vomiting, visual changes, neck stiffness, seizures (screen for intracranial complications)
2. Alarm Features
- Neurological symptoms: Headache, vomiting, drowsiness, seizures, cranial nerve palsies (especially CN VI, VII), strabismus, visual changes — suggest intracranial complications [5-7]
- Meningismus/neck rigidity: Meningitis or intracranial abscess [8]
- Vertigo: Labyrinthitis
- Facial nerve palsy: Direct extension of infection
- "Picket fence" fever (spiking/relapsing): Associated with venous sinus thrombosis [6]
- Postauricular fluctuance: Subperiosteal abscess
- Neck swelling below the ear: Bezold abscess (infection tracking along sternocleidomastoid) [8]
- Papilledema: Elevated intracranial pressure from cerebral venous sinus thrombosis (CVST) [7]
Intracranial complications were not always clinically apparent and were often detected on CT imaging even with low clinical suspicion. [8]
3. Medications
- Empiric IV antibiotics (first-line):
- Ampicillin-sulbactam or ceftriaxone — covers common pathogens (Streptococcus pneumoniae, S. pyogenes, H. influenzae) [1]
- Cefuroxime is also commonly used [9]
- Add metronidazole if anaerobic coverage needed (Fusobacterium necrophorum is associated with intracranial complications) [10]
- Duration: Typically 7–10 days IV, with transition to oral antibiotics guided by clinical response [9]
- Medication contributors: Prior incomplete or inadequate antibiotic courses for AOM may predispose to mastoiditis
- Caution: Oral antibiotics alone are insufficient for acute mastoiditis — IV therapy is standard
4. Diet
- No specific dietary triggers or recommendations
- Ensure adequate hydration, especially in febrile children
- NPO if surgical intervention is anticipated
5. Review of Systems
- ENT: Ear pain, ear drainage, hearing changes, tinnitus
- Neurological: Headache, vomiting, visual changes, altered mental status, seizures, facial weakness
- Constitutional: Fever, weight loss, fatigue
- Musculoskeletal: Neck pain or stiffness (Bezold abscess, meningitis)
- Ophthalmologic: Diplopia, blurred vision (CN VI palsy, papilledema from CVST)
6. Collateral History and Family History
- Vaccination status: Pneumococcal conjugate vaccine (PCV) — S. pneumoniae-positive cultures have decreased in the PCV era (from 30.9% to 10.3%), while Group A Streptococcus has increased [2]
- Under-immunization increases surgical likelihood [3]
- Daycare attendance, number of siblings, secondhand smoke exposure (AOM risk factors)
- Recurrent AOM history: Prior episodes, prior ear tube placement
- Family history of recurrent otitis media or immunodeficiency
7. Risk Factors
- Age <2 years: Higher symptom burden, higher inflammatory markers [2]
- Preceding or concurrent AOM (most common antecedent)
- Incomplete antibiotic treatment for AOM
- Under-immunization (especially PCV) [3]
- Winter/spring seasonality (peak in April) [4]
- Cochlear implant patients: Incidence ~1.7%, higher risk for complications [11]
- Immunocompromised states
- Lower socioeconomic status: Associated with higher complication and mastoidectomy rates [3]
8. Differential Diagnosis
- Periauricular cellulitis/abscess: Lacks middle ear findings; no TM abnormality
- Severe AOM without mastoiditis: No postauricular signs; responds to antibiotics
- Postauricular lymphadenitis: Discrete, mobile node; no TM changes
- Parotitis: Swelling anterior to ear, at angle of mandible
- Malignant (necrotizing) otitis externa: Older adults, diabetics, immunocompromised; Pseudomonas; skull base osteomyelitis
- Rhabdomyosarcoma or Langerhans cell histiocytosis: Rare; consider in atypical or non-resolving presentations
- Cholesteatoma with secondary infection: Chronic ear disease history
9. Past Medical History
- Recurrent AOM or chronic otitis media
- Prior tympanostomy tube placement
- Prior mastoiditis episodes
- Cochlear implant [11]
- Immunodeficiency (primary or acquired)
- Craniofacial anomalies (cleft palate, Down syndrome)
10. Physical Exam
- Vital signs: Fever (51–72% of cases), tachycardia [2][4]
- Postauricular findings (hallmark triad):
- Auricular protrusion (pinna pushed forward/outward) — present in 67–83% [2][4]
- Postauricular erythema and swelling
- Mastoid tenderness to palpation
- Postauricular fluctuance: Suggests subperiosteal abscess
- Otoscopy: TM erythema, bulging, perforation, otorrhea; sagging of posterosuperior EAC wall
- External auditory canal: Edema, narrowing
- Cranial nerve exam: Facial nerve (CN VII) function; CN VI (lateral gaze); fundoscopy for papilledema
- Neck exam: Assess for Bezold abscess (deep neck swelling along SCM)
- Neurological exam: Mental status, meningeal signs
Pearl: Auricular protrusion was independently associated with a lower likelihood of radiologic complications, suggesting it may indicate a more superficial disease process. [12]
11. Lab Studies
- CBC with differential: Leukocytosis (mean WBC ~16,000/nL); however, a normal WBC should not exclude the diagnosis [1][4]
- CRP: Typically elevated (mean ~60 mg/L); elevated WBC and CRP are independent predictors of CVST [4-5]
- Blood cultures: Obtain before antibiotics if systemically ill
- Middle ear/mastoid cultures: From otorrhea or myringotomy aspirate — guides targeted therapy
- Procalcitonin: May be considered but not well-validated for this indication
12. Imaging
- First-line: CT temporal bones with IV contrast — recommended when diagnosis is uncertain or complications are suspected [1][8]
- Demonstrates mastoid opacification, coalescence (air cell septal destruction), cortical erosion, subperiosteal abscess
- Erosion of the sigmoid sinus cortical plate is the most sensitive and specific CT finding for coalescent mastoiditis (sensitivity 67%, specificity 90%) [13]
- When to image: Not mandatory for all cases at admission; obtain if: [9]
- Diagnosis is uncertain
- Failure to improve within 48 hours of IV antibiotics [8]
- Clinical deterioration or suspicion of complications
- MRI brain with contrast: Superior for intracranial complications (CVST, epidural/subdural empyema, brain abscess) — preferred over CT when intracranial involvement is suspected [8]
- Imaging not always necessary: Uncomplicated cases with classic clinical findings may not require imaging, per the ACR Appropriateness Criteria [8]
13. Special Tests
- Myringotomy with culture: Both diagnostic and therapeutic; performed in most cases upon admission [14]
- Postauricular needle aspiration (PANA): For suspected subperiosteal abscess — can be both diagnostic and therapeutic, potentially avoiding mastoidectomy in ~71% of SPA cases [15]
- MR venography (MRV): For suspected CVST [7]
- Lumbar puncture: If meningitis is suspected; also therapeutic for elevated ICP secondary to CVST [7]
- Ophthalmologic exam: Fundoscopy for papilledema in suspected CVST
14. ECG
- Not routinely indicated
- Consider if sepsis or hemodynamic instability is present
- No specific ECG patterns associated with mastoiditis
15. Assessment
Staging (adapted from Häußler et al.): [4]
- Stage 1 — Mastoidal irritation: Postauricular erythema/tenderness without protrusion
- Stage 2 — Mild AM: Auricular protrusion, mild systemic symptoms
- Stage 3 — Advanced AM: Subperiosteal abscess, coalescence on imaging
- Stage 4 — Advanced AM with complications: Intracranial complications (CVST, abscess, meningitis)
Typical presentation: Child age 2–4 with recent AOM, fever, otalgia, postauricular swelling/erythema, and pinna protrusion. Atypical presentations include absence of mastoid swelling (27% of patients with intracranial complications presented without mastoid swelling) — maintain a high index of suspicion in patients with persistent fever, vomiting, or neurological symptoms after AOM. [6]
Complications: [1][8][10]
- Subperiosteal abscess (most common extracranial complication)
- Cerebral venous sinus thrombosis (most common intracranial complication)
- Epidural/subdural abscess, brain abscess
- Meningitis/encephalitis
- Facial nerve palsy
- Bezold abscess (deep neck)
- Labyrinthitis, hearing loss
16. Treatment Plan
Initial stabilization
Antibiotics
- Uncomplicated: IV ceftriaxone (50–100 mg/kg/day) or ampicillin-sulbactam (200–300 mg/kg/day of ampicillin component) [1]
- Suspected intracranial complications or anaerobic coverage: Add metronidazole (30 mg/kg/day divided q8h) — Fusobacterium necrophorum correlates with severe/intracranial complications [10]
- Duration: Typically 7–14 days IV, then transition to oral (total course guided by clinical response)
Surgical management
- Myringotomy ± tympanostomy tube: Performed in most cases upon diagnosis for drainage and culture [14]
- Subperiosteal abscess: Needle aspiration (PANA) or incision and drainage; consider mastoidectomy if abscess >20 mm or fails drainage [15-16]
- Cortical mastoidectomy: Reserved for failure of conservative management (no improvement in 48–72 hours), bony coalescence, or intracranial complications [3][14][17]
- Trend toward conservative management: In a U.S. national database, <40% of pediatric patients required surgery [3]
Anticoagulation: Consider for CVST (heparin or LMWH), in consultation with neurology/hematology [7]
17. Disposition
- Admit all patients with confirmed acute mastoiditis for IV antibiotics and monitoring [1][4]
- ICU admission: Sepsis, intracranial complications, altered mental status, hemodynamic instability
- Observation: Patients with mastoidal irritation (Stage 1) who are well-appearing may be observed closely with IV antibiotics
- ENT (Otolaryngology) consultation: Required for all cases — for myringotomy, abscess drainage, and potential mastoidectomy [1]
- Neurosurgery consultation: If intracranial abscess, subdural empyema, or need for craniotomy [16]
- Discharge criteria: Afebrile, clinically improving, tolerating oral antibiotics, reliable follow-up ensured
- Mean hospitalization: ~10 days for uncomplicated cases; ~15 days for intracranial complications [10][14]
18. Follow Up / Return Precautions
- Follow-up: ENT within 1–2 weeks of discharge; audiology assessment for hearing evaluation
- Recurrence monitoring: 32% of patients experienced new AOM episodes during follow-up [18]
- Return precautions — instruct to return immediately for:
- Recurrent or worsening fever
- Increasing ear pain or postauricular swelling
- Headache, vomiting, visual changes, or altered mental status
- Facial weakness or asymmetry
- Neck stiffness
- Seizures
- Expected recovery: Most patients recover fully; neurological sequelae occurred in ~5% and permanent hearing loss in ~3% of complicated cases [16]
- Vaccination: Ensure pneumococcal vaccination is up to date
References
1. High Risk and Low Prevalence Diseases: Acute Mastoiditis. — Bridwell RE, Koyfman A, Long B. The American Journal of Emergency Medicine. 2024.
2. Emerging Clinical Features of Acute Mastoiditis in Israel: A Registry Based Cohort. — Samuel O, Saliba W, Stein N, Shiner Y, Cohen-Kerem R. The Pediatric Infectious Disease Journal. 2024.
3. Contemporary Management of Acute Mastoiditis in Children: Insights From a U.S. National Database. — Hamdi O, Ramos L, Jamil T, et al. International Journal of Pediatric Otorhinolaryngology. 2026.
4. A Novel Diagnostic and Treatment Algorithm for Acute Mastoiditis in Children Based on 109 Cases. — Häußler SM, Peichl J, Bauknecht C, et al. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society European Academy of Otology and Neurotology. 2024.
5. Clinical Characteristics and Predictive Factors of Thrombotic Complications in Children With Acute Mastoiditis: A Single Center Retrospective Study. — Fiordelisi A, Soldovieri S, Trinci M, et al. European Journal of Pediatrics. 2025.
6. Clinical Outcomes of Intracranial Complications Secondary to Acute Mastoiditis: The Alder Hey Experience. — Krishnan M, Walijee H, Jesurasa A, et al. International Journal of Pediatric Otorhinolaryngology. 2020.
7. The Management of Elevated Intracranial Pressure and Sinus Vein Thrombosis Associated With Mastoiditis: The Experience of Eighteen Patients. — Havalı C, İnce H, Gündoğdu EB, et al. T Child's Nervous System : ChNS : Official Journal of the International Society for Pediatric Neurosurgery. 2022.
8. ACR Appropriateness Criteria® Inflammatory Ear Disease. — Agarwal M, Juliano AF, Hagiwara M, et al. Journal of the American College of Radiology : JACR. 2025.
9. Management of Pediatric Acute Mastoiditis in Israel: Nationwide Survey Among Otorhinolaryngologists and Emergency Pediatricians. — Tamir SO, Marom T, Rekhtman D, Luntz M. Pediatric Emergency Care. 2019.
10. Intracranial Complications of Acute Mastoiditis: Surgery Not Always Necessary. — Shinnawi S, Khoury M, Cohen-Vaizer M, Cohen JT, Gordin A. American Journal of Otolaryngology. 2024.
11. Acute Mastoiditis in Pediatric Cochlear Implant Patients - A Systematic Review. — Häußler SM, Böttcher A, Betz CS, Stölzel K, Meyer F. International Journal of Pediatric Otorhinolaryngology. 2025.
12. Pediatric Acute Mastoiditis: An Italian Multicenter Retrospective Study of Clinical, Microbiological, and Radiological Features. — Aricò MO, Trotta D, Accomando F, et al. European Journal of Pediatrics. 2026.
13. Computed Tomography and the Diagnosis of Coalescent Mastoiditis. — Antonelli PJ, Garside JA, Mancuso AA, Strickler ST, Kubilis PS. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 1999.
14. Algorithmic Management of Pediatric Acute Mastoiditis. — Psarommatis IM, Voudouris C, Douros K, et al. International Journal of Pediatric Otorhinolaryngology. 2012.
15. Management of Acute Mastoiditis With Immediate Needle Aspiration for Subperiosteal Abscess. — Bartov N, Lahav Y, Lahav G, et al. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society European Academy of Otology and Neurotology. 2019.
16. Surgical Management of Mastoiditis With Intratemporal and Intracranial Complications in Children. Outcome, Complications, and Predictive Factors. — Guillén-Lozada E, Bartolomé-Benito M, Moreno-Juara Á. International Journal of Pediatric Otorhinolaryngology. 2023.
17. Clarifying the Diagnosis and Management of Acute Uncomplicated Pediatric Mastoiditis. — Esce AR, Trujillo SA, Hawley KA. The Annals of Otology, Rhinology, and Laryngology. 2024.
18. Acute Mastoiditis: 30 Years Review in a Tertiary Hospital. — Veiga-Alonso A, Roldán-Pascual N, Pérez-Mora RM, et al. International Journal of Pediatric Otorhinolaryngology. 2025.