Mastoiditis surgery

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

Surgery

Surgical treatment in mastoiditis should be done in below conditions

• Intracranial complications.
• Cholesteatoma.
• Not achieving adequate response after 24 to 48 hours of starting treatment
• Evidence of postauricular fluctuation and subperiosteal abscess.
• Diagnosis of acute coalescent mastoiditis.
• Otorrhoea persisting for more than 2 weeks despite adequate antibiotic treatment.

Minimally invasive procedures:

• Incision and drainage of the mastoid abscess:
  • when fluctuation presents drainage must be done immediately and the pus should be to achieve complete drainage of the pus.
• Myringotomy:
  • It should be considered as a primary treatment in all cases of mastoiditis when there is an unperforated tympanic membrane or inadequate drainage. Myringotomy may be done with or without tympanostomy tube placement.
• Definitive surgery:
• Cortical mastoidectomy is the best choice of therapy; however if cholesteatoma is present, an open mastoidectomy should be performed.

Guidelines of management of mastoid abscess according to aetiopathology

1.

Acute coalescent mastoiditis without abscess formation.

•

Treatment is mainly medical in the form of intravenous antibiotics according to culture and sensitivity.

•

Myringotomy is needed in cases with insufficient drainage e.g. intact drum or small high perforation.

•

Treatment of the cause e.g. acute suppurative otitis media

2.

Acute coalescent mastoiditis presenting with a complication e.g. facial nerve paralysis or intracranial complications e.g. lateral sinus thrombophlebitis.

•

Treatment is mainly surgical under cover of broad spectrum intravenous antibiotics.

•

Treatment of the cause.

•

Intracranial complications such as brain abscess or meningitis should be co-managed with the neurosurgery department with priority going to the neurosurgery. When the patient is neurologically stable, management of the ear disease can be addressed.

3.

Acute mastoiditis with postauricular abscess.

•

Treatment is surgical in the form of cortical mastoidectomy after medical preparation with intravenous antibiotics.

•

In unfavourable circumstances, the abscess may be incised and drained followed a few days later by mastoidectomy.

•

Treatment of the cause.

4.

Acute mastoiditis complicating safe type of chronic suppurative otitis media.

•

Medical treatment similar to acute suppurative otitis media.

•

Treatment of the cause after the abscess has resolved e.g. tympanoplasty with cortical mastoidectomy.

5.

Acute mastoiditis on top of unsafe type of chronic suppurative otitis media (cholesteatoma).

•

Treatment is surgical in the form of open mastoidectomy under cover of intravenous broad spectrum antibiotic.

A postauricular fistula (Fig. 3) should be followed through the mastoid and totally excised, the skin edges should be freshened, undermined and carefully sutured in 2 layers.

The timing of surgery depends mainly on the patient’s condition and his response to the medical treatment. If the patient is deteriorating, surgery should be carried out promptly to save the patient’s life.

However, if the patient’s response to medical treatment is good, as evidenced by clinical improvement and a follow-up CT scan, the surgery may be postponed for one week to avoid perichondritis.

5.3. Guidelines of management of mastoid abscess according to aetiopathology

1.

Acute coalescent mastoiditis without abscess formation.

•

Treatment is mainly medical in the form of intravenous antibiotics according to culture and sensitivity.

•

Myringotomy is needed in cases with insufficient drainage e.g. intact drum or small high perforation.

•

Treatment of the cause e.g. acute suppurative otitis media

2.

Acute coalescent mastoiditis presenting with a complication e.g. facial nerve paralysis or intracranial complications e.g. lateral sinus thrombophlebitis.

•

Treatment is mainly surgical under cover of broad spectrum intravenous antibiotics.

•

Treatment of the cause.

•

Intracranial complications such as brain abscess or meningitis should be co-managed with the neurosurgery department with priority going to the neurosurgery. When the patient is neurologically stable, management of the ear disease can be addressed.

3.

Acute mastoiditis with postauricular abscess.

•

Treatment is surgical in the form of cortical mastoidectomy after medical preparation with intravenous antibiotics.

•

In unfavourable circumstances, the abscess may be incised and drained followed a few days later by mastoidectomy.

•

Treatment of the cause.

4.

Acute mastoiditis complicating safe type of chronic suppurative otitis media.

•

Medical treatment similar to acute suppurative otitis media.

•

Treatment of the cause after the abscess has resolved e.g. tympanoplasty with cortical mastoidectomy.

5.

Acute mastoiditis on top of unsafe type of chronic suppurative otitis media (cholesteatoma).

•

Treatment is surgical in the form of open mastoidectomy under cover of intravenous broad spectrum antibiotic.

●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