Mastoiditis surgery

Mastoiditis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Mastoiditis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Surgery

Complicated disease — Acute mastoiditis with extracranial or intracranial complications is usually treated with IV antibiotics, myringotomy with or without placement of a tympanostomy tube, and mastoidectomy [1,15,19,21]. However, we suggest that acute mastoiditis complicated by isolated facial nerve palsy be treated initially with IV antimicrobial therapy and myringotomy with or without placement of a tympanostomy tube [12]. (See 'Uncomplicated disease' above.)

We suggest that children with suppurative complications of acute mastoiditis other than facial nerve palsy be treated with IV antimicrobial therapy, myringotomy with or without placement of a tympanostomy tube, and mastoidectomy. (See 'Antimicrobial therapy' below and 'Drainage' below.)

Simple mastoidectomy in combination with antimicrobial therapy and tympanostomy tube placement is usually indicated as initial management when a subperiosteal abscess is noted at presentation [12,15]. However, some experts favor postauricular aspiration as the initial procedure [22].

Additional surgical interventions may be necessary for children with suppurative intratemporal or intracranial complications (eg, drainage of subperiosteal, subcutaneous, intratemporal, or intracranial collections, or thrombectomy) [1,11].

DRAINAGE — Treatment of acute mastoiditis usually requires the drainage of pus from the middle ear and/or mastoid cavity. Although there are reports of successful treatment without tympanocentesis or myringotomy [3], aspiration of middle-ear fluid is crucial in guiding definitive antimicrobial therapy. In addition, early drainage may interrupt the pathologic process and prevent complications [9]. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Pathogenesis' and "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications'.)

The indications for the various drainage procedures (tympanocentesis, myringotomy, myringotomy with placement of tympanostomy tube, mastoidectomy) vary from center to center depending on the pathologic stage (acute mastoiditis with periosteitis versus coalescent mastoiditis) and presence or absence and type of complications [1,11,27]. (See 'Overview of management' above.)

●Tympanocentesis – At a minimum, tympanocentesis should be performed in all children with mastoiditis to obtain middle-ear fluid for culture and susceptibility testing [1]. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Microbiologic studies'.)

●Myringotomy – Myringotomy (surgical perforation of the tympanic membrane) permits drainage of the middle ear; it may be performed with or without placement of a tympanostomy tube. Myringotomy permits drainage of the mastoid if the aditus ad antrum is not blocked (figure 1) [1]. A wide-field large myringotomy should be performed in children with acute mastoid osteitis to ensure adequate drainage [1].

●Tympanostomy tube placement – Tympanostomy tubes permit drainage over a longer duration than myringotomy alone [1]. At most institutions, it is standard to place a tympanostomy tube when myringotomy is performed to ensure sustained drainage. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children" and "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes'.)

●Mastoidectomy – Mastoidectomy is the surgical removal of the mastoid cortical bone and underlying air cells. In simple mastoidectomy (also called cortical, complete, or canal-wall-up mastoidectomy), the posterior portion of the external auditory canal is preserved. In radical mastoidectomy (also called canal-wall-down mastoidectomy), the posterior portion of the external auditory canal is sacrificed.

Simple mastoidectomy is performed to clean out the mastoid infection, open the aditus ad antrum, and provide external drainage [1]. Radical mastoidectomy is performed only when there is no clinical response to simple mastoidectomy, as evidenced by continued otorrhea or pain [1].

Indications for mastoidectomy may include [1,6,27]:

•Clinical findings consistent with subperiosteal abscess, such as postauricular fluctuance or mass (regardless of computed tomography [CT] findings)

•Computed tomography evidence of coalescent mastoiditis (regardless of other clinical features)

•Other suppurative complications of acute mastoiditis (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications')

•Acute mastoiditis in a child with chronic suppurative otitis media or cholesteatoma

•Progression of postauricular swelling or fluctuance or persistence of fever, ear pain, or drainage despite parenteral antimicrobial therapy and tympanocentesis/myringotomy