MastoiditisMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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718 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp62

Immediate priorities

›Airway and hemodynamic threats

›Septic shock physiology

›SBP < 90 mmHg

›MAP < 65 mmHg

›Altered mental status or GCS deterioration

›Intracranial complication until proven otherwise

›Urgent CT brain with contrast

›Seizures

›Intracranial abscess or meningitis trigger

›Benzodiazepine for active seizure

›If hemodynamically unstable, IV access and fluid resuscitation immediately

›Broad spectrum IV antibiotics within 1 hour

›Class I recommendation for sepsis

›Intracranial complication red flags

›Headache with vomiting

›Elevated intracranial pressure

›Cerebral venous sinus thrombosis (CVST)

›Papilledema on fundoscopy

›CVST with raised ICP

›Urgent neurology and neurosurgery consult

›Cranial nerve palsies

›CN VI (lateral gaze deficit)

›CN VII (facial weakness)

›Meningismus or neck stiffness

›Meningitis or epidural abscess concern

›Picket-fence spiking fever pattern

›Septic thrombophlebitis or CVST

02History/hx65

Presentation pattern

›Core syndrome

›Otalgia

›Worsening or recurrent after initial AOM treatment

›Severe or pulsatile quality

›Postauricular swelling and erythema

›Pinna displaced anteriorly

›Develops within 2 weeks of AOM

›Otorrhea

›Purulent discharge

›Possible spontaneous perforation

›Fever

›Common but not universal

›Persistent fever despite antibiotic course

›Antecedent AOM course

›Duration of preceding AOM

›Symptoms typically arise during or within 2 weeks

›Failure to respond to antibiotics is key feature

›Antibiotic history

›Course prescribed, duration, compliance

›Prior incomplete or inadequate courses increase risk

›Prior myringotomy or tympanostomy tubes

›Prior ear tube placement

›History of recurrent AOM

Alarm features

›Intracranial complication warning symptoms

›Headache

›New or worsening severity

03Physical Exam/exam60

Vitals and general

›Stability snapshot

›Temperature

›Fever in 51-72% of cases

›Hypothermia in severe sepsis

›Heart rate

›Tachycardia as infection severity marker

›Blood pressure

›SBP < 90 mmHg triggers sepsis pathway

›General appearance

›Irritability in infants beyond expected fever

›Toxic-appearing child warrants ICU concern

Postauricular and ear exam

›Hallmark triad of acute mastoiditis

›Auricular protrusion

›Pinna pushed forward and outward

›Present in 67-83% of cases

›Indicates subperiosteal collection or edema

›Postauricular erythema and swelling

›Overlying the mastoid process

›Distinguishes from simple AOM

›Mastoid tenderness to palpation

›Direct pressure over mastoid tip

›Otoscopy findings

›Tympanic membrane changes

›Erythema and bulging

›Perforation with otorrhea

›External auditory canal

04Differential Diagnosis/ddx49

Life-threatening mimics

›Intracranial infection

›Bacterial meningitis

›ICD-10 G00.9

›Fever, neck stiffness, photophobia without mastoid swelling

›Epidural or subdural abscess

›ICD-10 G06.0 or G06.1

›Complication of mastoiditis itself

›Brain abscess

›ICD-10 G06.0

›Focal neurological signs

›Cerebral venous sinus thrombosis

›ICD-10 G08

›Papilledema and elevated ICP

›Deep neck space infection

›Bezold abscess

›Extension along SCM from mastoid tip

›Neck mass with limited rotation

›Parapharyngeal or retropharyngeal abscess

›Dysphagia and drooling

›Deviated uvula

Common mimics

›Periauricular conditions

›Postauricular lymphadenitis

›Discrete mobile lymph node

›No tympanic membrane changes

›Periauricular cellulitis without mastoiditis

›Skin changes without mastoid tenderness

05Laboratory Tests/lt46

Core infection labs

›Complete blood count

›Leukocytosis typical

›Mean WBC approximately 16,000 per nL

›Normal WBC does not exclude diagnosis

›Neutrophilia with left shift

›Suggests bacterial infection

›Thrombocytosis

›Reactive inflammatory marker

›Inflammatory markers

›C-reactive protein

›Typically elevated; mean approximately 60 mg/L

›Elevated WBC and CRP are independent predictors of CVST

›Serial trending useful to assess treatment response

›Erythrocyte sedimentation rate

›Nonspecific but supports inflammation

›Procalcitonin

›May support bacterial infection

›Not well-validated specifically for mastoiditis

Microbiological studies

›Blood cultures

›Obtain before antibiotics in systemically ill patients

›Bacteremia present in minority of cases

›Guides targeted de-escalation

›Middle ear cultures

›Otorrhea swab culture

›From spontaneous perforation or myringotomy aspirate

›Common organisms

06Diagnostic Tests/dt76

Scoring Systems

›Mastoiditis staging (Haussler classification)

›Stage 1: Mastoidal irritation

›Postauricular erythema and tenderness

›No auricular protrusion

›No imaging coalescence

›Stage 2: Mild acute mastoiditis

›Auricular protrusion

›Mild systemic symptoms

›Stage 3: Advanced acute mastoiditis

›Subperiosteal abscess

›Coalescence on CT imaging

›Stage 4: Advanced mastoiditis with intracranial complications

›CVST, abscess, or meningitis

›Urgent neurosurgical and ICU involvement

›CVST risk prediction

›Independent predictors of CVST in mastoiditis

›Elevated WBC

›Elevated CRP

›Absence of auricular protrusion

›Symptom duration greater than 7 days

MRI

›MRI brain indications

›Preferred modality for intracranial complications

›Superior soft tissue resolution over CT

›Detection of early cerebritis before abscess formation

›Specific indications

›Suspected epidural or subdural empyema

07Disposition/dispo49

Admission criteria

›All confirmed acute mastoiditis requires hospital admission

›IV antibiotics mandatory

›Oral antibiotics alone insufficient

›Class I expert consensus recommendation

›ENT consultation required for all cases

›Myringotomy and drainage planning

›Mastoidectomy decision

›Standard admission indications

›Any stage of acute mastoiditis with classic signs

›Postauricular swelling with fever

›Pinna protrusion

›Failure to improve with outpatient antibiotics

›Worsening ear pain despite oral antibiotics

›Persistent fever beyond 48-72 hours

›Mean hospitalization duration

›Approximately 10 days for uncomplicated cases

›Approximately 15 days for intracranial complications

ICU indications

›Critical care escalation criteria

›Septic shock

›Vasopressor requirement

›Persistent hypotension despite fluids

›Intracranial complications

›Impaired consciousness

›Seizures requiring airway protection

›Refractory elevated ICP

›Post-operative monitoring

08Treatment/t86

Initial stabilization

›Supportive measures

›IV access and fluid resuscitation

›Isotonic crystalloid for dehydration

›20 mL/kg bolus in children with signs of shock

›Antipyretics

›Acetaminophen 15 mg/kg PO or PR every 4-6 hours

›Ibuprofen 10 mg/kg PO every 6-8 hours (if no contraindications)

›Analgesia

›Acetaminophen or ibuprofen as above

›Opioid analgesia for severe pain in adults

›NPO if surgical intervention anticipated

›Myringotomy or mastoidectomy planning

Empiric IV antibiotic therapy

›First-line regimens

›Ceftriaxone IV (children)

›50-100 mg/kg/day divided every 12-24 hours

›Maximum 2 g per dose

›Covers S. pneumoniae and S. pyogenes

›Ampicillin-sulbactam IV (children)

›200-300 mg/kg/day of ampicillin component divided every 6 hours

›Maximum 8 g ampicillin per day

›Broader spectrum including beta-lactamase producers

›Ceftriaxone IV (adults)

›2 g IV every 12-24 hours

›Standard uncomplicated mastoiditis

›Ampicillin-sulbactam IV (adults)

›3 g IV every 6 hours

›Renal dose adjustment when GFR impaired

›When to add anaerobic coverage

›Metronidazole IV addition

›Children: 30 mg/kg/day divided every 8 hours

›Adults: 500 mg IV every 8 hours

›Indications: Suspected Fusobacterium necrophorum, intracranial abscess, coalescent mastoiditis

›Fusobacterium correlates with intracranial complications

›Piperacillin-tazobactam IV

›Adults: 4.5 g IV every 6 hours

›When Pseudomonas coverage needed

›Chronic or complicated cases

Antibiotic duration and de-escalation

›IV to oral transition

›Typical IV course

›7-14 days IV depending on severity

›Transition to oral guided by clinical response

›Oral step-down options

›Amoxicillin-clavulanate 875 mg PO every 12 hours (adults)

›Amoxicillin-clavulanate 45 mg/kg/day divided every 12 hours (children)

›Total course guided by clinical and radiologic response

›Culture-directed therapy

›Narrow spectrum based on culture and sensitivity

›De-escalate from broad coverage when culture available

Anticoagulation for CVST

›Anticoagulation decision

›Heparin or LMWH consideration for CVST

›Low molecular weight heparin: enoxaparin 1 mg/kg SC every 12 hours (adults)

›In consultation with neurology and hematology

›Decision weighs thrombosis extension vs bleeding risk

›Duration of anticoagulation

›Typically 3-6 months depending on thrombus resolution

›MRV follow-up to guide duration

Surgical management

›Myringotomy and tympanostomy tube

›Performed in most cases upon admission

›Drainage of middle ear and mastoid

›Microbiological specimen collection

›Therapeutic pressure relief

›Indications

›Bulging tympanic membrane

›Absence of spontaneous perforation

›Subperiosteal abscess management

›Postauricular needle aspiration (PANA)

›First-line for subperiosteal abscess

›Can avoid mastoidectomy in approximately 71% of cases

›Preferred if abscess accessible and less than 20 mm

›Incision and drainage

›When needle aspiration fails or abscess too large

›Abscess greater than 20 mm or failed PANA

›Cortical mastoidectomy

›Reserved for failure of conservative management

›No improvement within 48-72 hours of IV antibiotics

›Bony coalescence confirmed on CT

›Intracranial complications requiring surgical access

›Less than 40% of pediatric patients required surgery in national database study

›Neurosurgical intervention

›Craniotomy or burr hole drainage

›Intracranial abscess greater than 2.5 cm

›Subdural empyema

›Neurosurgery consult for all intracranial complications

›Lumbar puncture for ICP management

›Therapeutic CSF drainage in CVST with raised ICP

›In consultation with neurology

09Special Populations/sp66

Pregnancy

›Pregnancy considerations

›General management principles unchanged

›IV antibiotics mandatory

›ENT consultation required

›Antibiotic safety in pregnancy

›Beta-lactams preferred (ceftriaxone, ampicillin-sulbactam)

›Category B safety in pregnancy

›Metronidazole generally avoided in first trimester

›Avoid tetracyclines and fluoroquinolones

›Imaging approach in pregnancy

›CT temporal bones with lead shielding when necessary

›MRI preferred when intracranial complication suspected

›Gadolinium contrast use limited to essential indications

›Maternal monitoring

›Maintain SpO2 >= 95% when septic

›Fetal monitoring when viable gestation and maternal sepsis

›Anticoagulation for CVST

›LMWH preferred over heparin during pregnancy

›Warfarin avoided; teratogenic in first trimester

Geriatric

›Older adult features

›Atypical presentation

›Afebrile infection more common

›Delirium may be primary symptom

›Postauricular signs may be subtle

›Malignant otitis externa overlap

›Pseudomonas aeruginosa in diabetics and immunocompromised

10Background/b81

Epidemiology

›Incidence and distribution

›Most common in children

›Mean age 2-4 years

›Can occur at any age including adults

›Seasonal pattern

›Peak incidence during winter months

›Peak presentation in April in some cohorts

›Complication rates

›Intracranial complications in 6.5-13.7% of cases

›Subperiosteal abscess is most common extracranial complication

›CVST is most common intracranial complication

›Pathogen trends

›Pre-PCV era

›Streptococcus pneumoniae dominant pathogen

›S. pneumoniae in 30.9% of positive cultures

›Post-PCV era

›S. pneumoniae decreased to 10.3% of positive cultures

›Group A Streptococcus and Fusobacterium necrophorum increasing

›Fusobacterium necrophorum

›Associated with intracranial complications

›Anaerobic coverage critical when suspected

Pathophysiology

›Disease progression mechanism

›Acute otitis media as primary antecedent

›Infection spreads from middle ear to mastoid air cells

›Air cells normally communicate with middle ear

›Mastoidal inflammation and edema

›Aditus ad antrum blockage

›Impaired drainage of mastoid air cells

›Mucoid to purulent exudate accumulation

›Coalescent mastoiditis

›Suppurative osteitis of mastoid septa

›Air cell walls destroyed

›Coalescent abscess cavity formation

›Extracranial complication pathways

›Subperiosteal abscess

›Pus tracks through lateral cortex into subperiosteal space

›Most common complication (35-40% of mastoiditis cases)

›Bezold abscess

›Pus tracks inferiorly through mastoid tip

›Spreads along sternocleidomastoid to neck

›Labyrinthitis

›Direct extension to inner ear

›Sensorineural hearing loss and vertigo

›Intracranial complication pathways

›CVST mechanism

›Retrograde septic thrombophlebitis of emissary veins

›Sigmoid sinus most commonly affected

›Extension to transverse sinus and superior sagittal sinus

›Epidural abscess

›Pus accumulation between dura and temporal bone

›Dura acts as partial barrier

›Subdural empyema and brain abscess

›Breakthrough dural barrier or haematogenous seeding

›Requires neurosurgical intervention

Therapeutic Considerations

›Antibiotic strategy principles

›IV antibiotics mandatory for all confirmed cases

›Oral antibiotics insufficient for acute mastoiditis

›IV duration typically 7-14 days before oral transition

›Empiric pathogen coverage

›S. pyogenes and S. pneumoniae primary targets

›Fusobacterium coverage when intracranial complications present

›Anti-pseudomonal coverage for chronic or immunocompromised cases

›Culture-directed de-escalation

›Myringotomy culture guides targeted therapy

›Narrow spectrum when clinical response confirmed

›Surgical management philosophy

›Conservative approach preferred where feasible

›Less than 40% of pediatric cases required surgery in national database

›PANA avoids mastoidectomy in approximately 71% of subperiosteal abscess cases

›Mastoidectomy triggers

›No clinical improvement within 48-72 hours

›Coalescent mastoiditis on CT

›Failed abscess drainage

›Intracranial complications

›Outcomes

›Most patients recover fully

›Neurological sequelae in approximately 5% of complicated cases

›Permanent hearing loss in approximately 3% of complicated cases

›Recurrence monitoring

›32% of patients experienced new AOM episodes in follow-up

›Audiology assessment for hearing evaluation at discharge

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Mastoiditis home care after discharge

›Complete the full antibiotic course as prescribed

›Do not stop early even if feeling better

›Take with food to reduce stomach upset

›Pain and fever management

›Acetaminophen or ibuprofen as directed by your doctor

›Keep ear dry; avoid swimming or submerging the ear

›Rest and hydration

›Adequate fluid intake especially in children

›Limit strenuous activity until cleared by doctor

›Ear care

›If tympanostomy tube was placed, keep ear canal dry

›Do not insert objects into the ear canal

›Warning signs to return to the emergency room immediately

›Return to ER if any of the following develop

›Worsening ear pain or swelling behind the ear

›Return of fever or fever not improving after 48 hours of antibiotics

›Headache that is severe or new

›Vomiting that is persistent or repeated

›Neck stiffness or inability to touch chin to chest

›Confusion, unusual sleepiness, or difficulty waking

›Seizures

›Facial weakness or drooping on one side

›Double vision or vision changes

›Swelling in the neck

›Hearing significantly worse than at discharge

›Follow-up appointments

12References/r35

Guidelines and key sources

›Primary guideline documents

›ACR Appropriateness Criteria: Inflammatory Ear Disease (Agarwal et al. 2025)

›CT temporal bones with contrast is appropriate for suspected acute mastoiditis

›MRI brain preferred when intracranial complications suspected

›ACEP Clinical Policy framework for head and neck infections

›Level C evidence for imaging thresholds in mastoiditis

›Key evidence sources

›Bridwell, Koyfman, Long. American Journal of Emergency Medicine 2024

›High risk and low prevalence diseases: acute mastoiditis

›Comprehensive EM review and management framework

›Haussler SM et al. Otology and Neurotology 2024

›Novel diagnostic and treatment algorithm based on 109 cases

›Staging system for acute mastoiditis

›Samuel O et al. Pediatric Infectious Disease Journal 2024

›Registry-based cohort; emerging clinical features in Israel

›Fever in 51-72%; auricular protrusion in 67-83%; CVST predictors

›Hamdi O et al. International Journal of Pediatric Otorhinolaryngology 2026

›Contemporary management from US national database

›Less than 40% of pediatric cases required surgery

›Fiordelisi A et al. European Journal of Pediatrics 2025

›Predictive factors for thrombotic complications

›Elevated WBC and CRP independent predictors of CVST

›Bartov N et al. Otology and Neurotology 2019

›PANA avoids mastoidectomy in approximately 71% of subperiosteal abscess cases

›Antonelli PJ et al. Otolaryngology Head Neck Surgery 1999

›CT: sigmoid sinus cortical plate erosion sensitivity 67%, specificity 90%

›Coding references

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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