Brief overview
- Symptoms: Pressure- and pain-sensitive swelling and redness behind the ear, fever, declining hearing, fatigue, fluid discharge from the ear; in masked form, more nonspecific symptoms such as abdominal pain and headache
- Treatment: antibiotic administration, often via the bloodstream, usually surgery with removal of the inflamed area
- Causes and risk factors: Bacterial infection usually after middle ear infection treated too late or not long enough; impeded secretion drainage or a weakened immune system favor its development
- Diagnosis: Medical history, external examination, otoscopy, hearing test, further examinations; to find complications, among other things, X-ray and computer tomography.
- Prognosis: If treated in time, the disease usually heals quickly and permanently; if left untreated, life-threatening complications such as abscesses in the brain are possible.
What is mastoiditis?
Mastoiditis (also called mastoiditis) is a purulent inflammation of the bone located behind the ear. This bone (medically called the os mastoideum or mastoid) has an elongated, pointed shape that remotely resembles a wart, hence the name mastoid process (pars mastoidea).
The interior of the mastoid process is not completely filled with bone mass; its interior is partially filled with cavities lined with mucosal cells. In mastoiditis, inflammation exists here.
Mastoiditis is the most common complication of otitis media today. Middle ear infections mainly affect children and adolescents, while adults are less frequently affected. Therefore, mastoiditis occurs more frequently in childhood. It is a rare disease due to the good treatment options for otitis media. 1.2 to 1.4 children out of 100,000 children are affected by this complication.
Chronic mastoiditis
To be differentiated from acute mastoiditis is chronic mastoiditis, also known as masked mastoiditis or veiled mastoiditis. Chronic mastoiditis occurs somewhat less frequently than acute mastoiditis, but is more dangerous. In this case, the mastoid process also becomes inflamed. However, this inflammation does not manifest itself with the classic symptoms of mastoiditis (such as fever or pain).
How do you recognize mastoiditis?
The symptoms of mastoiditis appear about two to four weeks after the onset of acute otitis media. In most cases, the symptoms are already subsiding and suddenly flare up again. The reason may then be mastoiditis.
In general, the symptoms of mastoiditis are similar to those of otitis media. For a layperson, it is therefore very difficult to distinguish between the two diseases. Either way, it is advisable to have them treated as soon as possible. As a general rule, it is therefore advisable to consult a doctor as a precautionary measure if one or more of the following symptoms occur:
- Pain in and around the ear. A constant, throbbing pain is typical.
- “Pulse throbbing” in the ear
- Prolonged fever
- Hearing deteriorates
- Restlessness, sleep disturbances, violent crying (in infants)
- Fatigue
If the swelling is severe, it pushes the ear down sideways. As a result, the auricle protrudes significantly. In addition, large amounts of a milky fluid often empty from the ear. The patient may refuse food and appear apathetic.
In young children, it is difficult to determine exactly what the symptoms are. A sign of both otitis media and mastoiditis is when children frequently grab their ears or shake their heads back and forth. Many young children experience nausea and vomiting. Mastoiditis is often less severe in babies than in older children.
How does masked mastoiditis present?
Masked or chronic mastoiditis is not clearly indicated by symptoms such as swelling or redness. Rather non-specific symptoms such as general fatigue, abdominal pain, headache, fatigue or loss of appetite occur.
How to treat mastoiditis?
The doctor treats mastoiditis like other bacterial infections with antibiotics. Depending on which pathogens are responsible for the mastoiditis, different antibiotics are particularly helpful. If the exact pathogens are not (yet) determined, the doctor usually uses a broad-spectrum antibiotic, such as an active ingredient from the penicillin group. They are effective against a variety of different bacteria, but are particularly effective against staphylococci and streptococci, the most common pathogens of mastoiditis.
In babies and young children, the doctor administers antibiotics most easily through the vein (by infusion, “intravenously”). This ensures that the medication actually ends up in the bloodstream and is not spat out again.
Mastoiditis – when is surgery necessary?
If the mastoiditis is very pronounced or there is no improvement even after a few days of treatment, surgical removal of the swelling is necessary. For this purpose, the doctor removes the inflamed areas of the mastoid process (mastoidectomy). Doctors assume that surgery is almost always necessary. Only a few cases are treated with antibiotics.
Two methods of surgery are available, simple and radical mastoidectomy. In simple mastoidectomy, only the cells of the mastoid process affected by the inflammation are removed. In radical mastoidectomy, on the other hand, the practitioner removes additional structures. These include the posterior wall of the external auditory canal and the upper part of the tympanic cavity of the middle ear.
To allow the fluid (usually pus) to escape from the ear, the doctor places a thin tube (drainage) during the operation, through which the pus is drained.
The operation is always performed as an inpatient. A small incision is made behind the ear through which the surgery is performed. The incision heals quickly.
After surgery, affected individuals must remain in the hospital for about a week. After that, they are usually symptom-free. Accompanying the surgery, therapy with antibiotics is given to kill any remaining bacteria in the body.
What can be done in the event of chronic mastoiditis?
Once diagnosed, the doctor treats chronic mastoiditis with antibiotics and, in most cases, surgery.
Causes and risk factors
Causes of mastoiditis in babies and children are usually bacteria such as pneumococci, streptococci and Haemophilus influenzae type b, and often staphylococci in babies. Since there is no external route leading directly to the mastoid process, mastoiditis is usually a result of other diseases.
In most cases, mastoiditis is preceded by a regular chain of infections. Children quickly and frequently become infected with various types of viruses, which then cause inflammation of the throat and pharynx. The viral infection lowers the body’s defenses. Thus, an additional infection with bacteria (superinfection) easily develops.
Impeded secretion drainage during infections favors mastoiditis. This occurs, for example, in the case of a severely swollen nose or blocked ears. A weakened immune system also favors infections. A weakening of the immune defense occurs, for example, in the context of therapy with some antibiotics or corticosteroids (for example, cortisone), as well as in certain chronic diseases (for example, an HIV infection or diabetes mellitus).
Examinations and diagnosis
If mastoiditis is suspected, an ear, nose and throat (ENT) specialist is the right person to contact. In an initial consultation, he or she will take your medical history (anamnesis). You will have the opportunity to describe your symptoms in detail. In the case of children, the parents usually provide information. The doctor will ask questions such as:
- Have you (or your child) recently suffered from an infection?
- How long have you had the symptoms?
- Have you noticed discharge from the ear?
With the help of an ear mirror (otoscope), he examines the eardrum and the external auditory canal. This examination is called otoscopy. If there is a swelling of the eardrum, this is detected, among other things, by a light reflex, which is located in a different place on the eardrum than in a healthy ear. In addition, the ear is reddened from the inside.
Further diagnosis is made in a hospital if there is a well-founded suspicion of mastoiditis. This is useful so that therapy can begin as soon as possible and because surgical intervention may be necessary. At this point, at the latest, a blood count is taken. If there is inflammation in the body, certain values of the blood test are elevated. These include the number of white blood cells (leukocytes), the value of C-reactive protein and the blood cell sedimentation rate.
Doctors further confirm the diagnosis with the help of an X-ray or a computer tomography. The resulting images show any complications – for example, if pus has accumulated in surrounding areas.
It is often difficult to take an X-ray and a computer tomography of small children because they often do not lie still enough. Therefore, in some cases, if there are clear findings that support the suspicion of mastoiditis, physicians do not perform these additional examinations.
A hearing test is also usually part of an examination.
Course of the disease and prognosis
The prognosis of mastoiditis depends on when the infection is detected. To avoid secondary diseases, the doctor treats mastoiditis as soon as possible. The later the therapy begins, the more time the bacteria have to spread in the body and the more likely complications will occur.
If therapy is started in time, complications of mastoiditis can usually be avoided. With consistent treatment, mastoiditis heals within a few days to weeks. In the meantime, the symptoms continue to decrease. Permanent damage, such as hearing loss, rarely occurs.
Complications of mastoiditis
If mastoiditis remains untreated, however, serious complications are possible. If the accumulation of pus does not drain to the outside, it will seek escape routes around the mastoid process. This may result in an encapsulated collection of pus below the mastoid in the periosteum.
It is also possible for pus to penetrate between the bones and the outermost meninges (epidural abscess). It is also possible for pus to penetrate the lateral muscles of the neck (Bezold abscess).
It is possible for the bacteria to spread further in the body from the mastoid process. It is particularly dangerous if they spread to the meninges (meningitis) or to the inner ear (labyrinthitis). If the bacteria enter the bloodstream, blood poisoning (sepsis) occurs, which is even fatal under unfavorable circumstances.
The facial nerve, which is responsible for the facial muscles among other things, also runs near the mastoid. If this is damaged, permanent deafness and facial paralysis are possible consequences.
If complications arise, mastoiditis can take a life-threatening course in extreme cases. If the symptoms of a middle ear infection do not improve or if they reappear after completion of antibiotic therapy, please consult your doctor.
Prevention
It is important that you have an occurring middle ear infection treated immediately. In doing so, it is advisable to follow the doctor’s instructions without fail. If you do not take the antibiotic regularly or take it for too short a time, it is possible that some bacteria will survive in the ear and multiply again after you stop taking the antibiotic.
If, in the case of a middle ear infection, the symptoms have not subsided after two weeks, if they increase despite treatment, or if they recur after some time, consult a doctor again to reduce the risk of mastoiditis.
