​Kembara Xtra - Medicine - Mastoiditis

​Kembara Xtra - Medicine - Mastoiditis 
An inflammation of the mastoid bone is called mastoiditis.
Most frequently, it occurs as a side effect of acute otitis media (AOM).

● Typically, days to weeks following the onset of the initial middle ear symptoms, clinical indications of mastoiditis occur.
 Divided into sections based on pathologic stage:
- Purulent material in the mastoid cavities caused by acute mastoiditis with periostitis (incipient mastoiditis). Typically, symptoms last one month or less.
- Coalescent mastoiditis, also known as acute mastoid osteitis, is characterized by the breakdown of the delicate bone septae between air cells, which is followed by the development of abscess cavities with pus spreading into nearby areas.
 Patients with persistent middle ear effusion or recurrent episodes of inadequately treated AOM are at risk for developing masked mastoiditis (subacute mastoiditis), a low-grade, persistent infection that destroys the bone septae connecting air cells.
Chronic mastoiditis is linked to persistent otitis media that has not responded to treatment. Frequently linked to cholesteatoma; symptoms can continue for years.

Epidemiology 

Children under the age of two have the highest frequency; males who attend daycare are similar to the population at risk for AOM; and suppurative AOM is less prevalent if immunizations are current and antibiotics are used to treat it
In the United States, there are 1 to 2 cases per 100,000 children per year.


Pathophysiology and Etiology 
AOM and irritation of the mastoid air cells signal the start of the subclinical stage.
The petrous temporal bone's mastoid is made up of air-filled cells.
Middle ear and mastoid air cells are connected via the mastoid aditus and antrum, which is a small passageway.
- Middle ear fluid can restrict the outflow tract of mastoid air cells at the aditus or antrum.
- In cases of acute mastoiditis with periosteitis, edema and accumulation of purulent material most frequently extend from mastoid air cells to periosteum via mastoid emissary veins with penetration of periosteum.
Acute coalescent mastoiditis/mastoid osteitis causes the loss of bone septae due to increased pressure from fluid within the air cells.
 With the development of an abscess, acute mastoid osteitis can spread to other sites in the head and neck:
- Suppurative labyrinthitis, Bezold abscess, subperiosteal abscess (most frequent consequence), and suppurative CNS problems
Acute mastoiditis: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, group A streptococci (Streptococcus pyogenes, Staphylococcus aureus, including methicillin-resistant S. aureus [MRSA]), and Fusobacterium necrophorum
Pseudomonas aeruginosa, S. aureus, anaerobic bacteria, polymicrobials (organisms present in the external ear canal), and Mycobacterium tuberculosis are the most common causes of chronic mastoiditis. Abscesses are caused by S. aureus, mycobacteria, and Aspergillus.
Genetics No genetic pattern is known

Risk Factors Cholesteatoma manifests as a squamous pearl in the middle ear's anterior superior region, close to the tympanic membrane.
Chronic suppurative otitis media or recurrent AOM
Immunocompromised condition

Basic Prevention 
Ensure that vaccines are current, especially the pneumococcal vaccine.
 ENT referral for persistent otitis media
 Correct AOM diagnosis and care; stop recurrence of AOM.
– The use of chemotherapy for AOM is debatable. Consider historically children with two AOM events in the first six months of infancy, or older children with three or four occurrences in a year. Due to concerns about drug resistance, the American Academy of Pediatrics does not currently advise chemotherapy.
Wear earplugs when swimming or taking a shower if you have AOM, and take pressure equalization tubes to treat chronic eustachian tube dysfunction.
 Cholesteatoma early detection

Accompanying Conditions 

Otitis media with pus

History: Lethargy, malaise, irritability, fever, poor feeding, decreased appetite; recent ear infection; otorrhea (ear infection drainage); otalgia and/or pain on the mastoid bone behind the ear; swelling or redness over the mastoid; swelling of the ear lobe; headache; hearing loss; chronic: persistent ear drainage; persistent ear pain; chronic: AOM nonresponsive to antibiotic; suspicion for mastoi

clinical assessment 

● Acute:
- Fever - Postauricular erythema, discomfort, and/or edema overlaying the mastoid
- Postauricular fluctuation that can be felt (a later finding) is typically postauricular in children over 1 year old and above the ear in children under 1 year old.
- Displaced pinna that is up and outward in children older than 1 year olds, or down and outward in younger youngsters- Otoscopic examination: AOM present, maybe with TM perforation and purulent discharge.
 Prolonged mastoiditis
- Continuous or irregular mucopurulent discharge
- Reduced hearing - A chronic process that may be painless
- Otoscopic exam: mucopurulent discharge and possible TM perforation

Mumps, parotitis, severe otitis externa, periauricular cellulitis, aneurysmal bone cysts, fibrous dysplasia, acute lymphocytic leukemia, acute myelogenous leukemia, Burkitt lymphoma, non-Hodgkin lymphoma, rhabdomyosarcoma, and neuroblastoma are among the differential diagnoses.
Deep-space infections in the neck

Laboratory Results 

Initial examinations (lab, imaging)
Elevated erythrocyte sedimentation rate (ESR) and Creactive protein (CRP) in acute but potentially normal in chronic (CBC with differential)
 Blood tests
Send for cultures, Gram stains, and acid-fast stains after myringotomy or tympanocentesis. Send for cultures and stains after aspiration if postauricular fluctuance is observed.
Plain films of the mastoid have a low diagnostic yield but may reveal demineralization of the bony septa, clouding of the mastoid air cells, or loss of the crisp shape of the mastoid (3).
These alterations do not serve as a diagnosis and are also present in AOM.
The CT of the temporal bone is preferred because it has a 94% positive predictive value for finding intracranial problems and a 77% sensitivity.- Air cell clouding or opacification (also in AOM)
- Coalescence of mastoid air cells.
- Cortical bone degradation - Fluid collections that enhance the rim
- Mastoid opacification excludes the diagnosis in the absence of it.
If complications (suppurative extension) are suspected, use a CT with contrast.
Due to the radiation risk, CT scans for kids should only be done under medical supervision. Symptoms include: - Lethargy/vomiting - Neurologic signs
- Possibility of cholesteatoma
Technetium-99m bone scan is more sensitive to osteolytic alterations than CT. - Fever after 48 to 72 hours of therapy.
Middle ear cleft - Needed to screen for cerebral consequences if clinical or radiographic suspicion exists. Consider MRA if venous sinus thrombosis is suspected. MRI: partial-to-complete opacification of the mastoid air cells.
Additional Tests & 

Particular Considerations
In symptomatic, immunocompromised individuals, interpret normal WBC with caution. Send all cultures for aerobic and anaerobic growth.
Consider immunologic testing in children with repeated bouts of OM that result in mastoiditis. Lumbar puncture if meningitis is suspected.
Other/Diagnostic Procedures
Obtain CSF if cerebral extension is suspected. Obtain middle ear fluid through tympanocentesis for culture and sensitivity. Myringotomy with culture (also therapeutic).
 Tympanostomy or TM tube with biopsy tissue protruding

Management 

The preferred treatment for uncomplicated acute mastoiditis is IV antibiotics and myringotomy (tympanostomy tubes), reflecting a move away from more invasive surgical treatment.
If patients don't improve after 3 to 5 days of treatment, a simple mastoidectomy is advised to prevent cerebral problems.
If there is an abscess in the mastoid air cells, myringotomy or incision and drainage may be required.

General Actions 
hospitalization during the acute phase of IV antibiotic therapy


First Line of Medicine
Empiric antibiotics are used to treat the majority of common bacteria, including S. pneumoniae, S. pyogenes, S. aureus, MRSA, and P. aeruginosa.
Use combination therapy with clindamycin and a third-generation cephalosporin (ceftriaxone or cefotaxime) to treat resistant strains.
Ceftriaxone 2 g IV q24h - Children's dosage: 50 to 75 mg/kg/day divided by IV every 12 to 24 hours
- Caution: If you have renal impairment, adjust your dose.
Consider levofloxacin 750 mg IV every 24 hours if you have a severe -lactam allergy.
Clindamycin for treatment of S. pneumoniae resistant to ceftriaxone in pediatric patients:
Pediatric doses of cefotaxime range from 1 to 2 g IV every 4 to 8 hours, depending on the severity of the condition.
- For children, administer 100 to 200 mg/kg/day q6-8h; if MRSA or an acute exacerbation of a chronic condition is suspected, add vancomycin 30 to 60 mg/kg/day divided q8-12h.
Pediatric dosage: 15 mg/kg/dose every 6 to 8 hours; use cautiously if renal function is impaired.
Treatment with piperacillin and tazobactam 3.375 g IV every six hours is advised for patients with a history of recurrent AOM or recent antibiotic use:
When culture data are available, tailor treatment based on antibiotic sensitivities. - Pediatric dosing: 300 mg/kg/day based on piperacillin component divided q6-8h.
Next Line
Oral antibiotics after receiving IV antibiotics for 7 to 10 days and after myringotomy/blood cultures have determined the pathogen and its sensitivities. For intracranial problems, common oral antibiotics include clindamycin plus a third-generation cephalosporin for 3 weeks or a total treatment period of 4 weeks or longer (5).
For persistent mastoiditis: Apply topical drops three to four times daily ofloxacin otic solution (0.3%), neomycin, polymyxin B, or hydrocortisone.

Referral 
For both adults and children with mastoiditis, consult ENT; for complications involving the intracranial space, consult neurosurgery.
Consider consulting an infectious disease specialist for help managing your antibiotic use.

Surgical Techniques 

 Use tympanocentesis to collect cultures and inform antibiotic selection.
Middle ear drainage is made possible through tympanostomy tubes and myringotomies.
Simple mastoidectomy is most effective for managing subperiosteal abscesses if trial of conservative therapy (drainage, myringotomy, and IV antibiotics) fails. Cleaning the ear canal under microscopic guidance will ensure pressure-equalization tube patency and adequate middle ear drainage.


Alternative Therapies 
 No known home cures 

Admission 
Initial stabilization and admission requirements
Hospitalize patients with acute mastoiditis and begin IV antibiotics very away. - Clinical or radiological signs of acute mastoiditis.
Keep your affected ear from getting wet.
Discharge requirements: Clinical improvement; afebrile for 48 hours before IV antibiotics are stopped; ability to tolerate oral antibiotics


Follow Up 
Oral antibiotics for three weeks after an IV antibiotic course (the total length of antibiotic treatment is four weeks or more for intracranial problems).
Consider using amoxicillin for several months as an antimicrobial prophylactic for chronic mastoiditis.
patient observation
 After the acute situation has passed, perform a postoperative audiogram to check for hearing loss.
 Monitor individuals who have hearing loss and/or intracranial problems with ENT and/or neurosurgery.


Patient Education 
Avoid getting the afflicted ear wet, and finish the entire antibiotic course.
PROGNOSIS Relies on the disease's intensity and stage.
If a mastoiditis diagnosis is made quickly and the condition is properly treated, the majority of cases totally recover.
Hearing loss brought on by conductive hearing loss may require reconstructive surgery; it may also be permanent.


Complication 
Rate of complications: 5-29% 
Extracranial: Citelli abscess (osteomyelitis of the calvaria) - Osteomyelitis of the temporal bone; suppurative labyrinthitis - Permanent hearing loss; subperiosteal abscess (osteomyelitis of the calvaria), which is the most common; Bezold abscess (abscess of the sternocleidomastoid muscle, sneaky, danger
- Paralysis of the facial nerves
Epidural, subdural, and cerebral intracranial abscesses are possible.
- Hearing loss - Meningitis, cerebritis, and periodontitis
Reduced venous drainage from otitis hydrocephalus results in benign intracranial hypertension, which manifests as increased intracranial pressure, headache, papilledema, and sixth nerve palsy.
Encephalitis, brain abscess, and Gradenigo syndrome (palsy of the sixth nerve, excruciating pain in the fifth nerve's distribution, and suppurative OM
- Lateral sinus thrombosis; central venous sinus thrombosis  - Sigmoid sinus thrombophlebitis or thrombosis

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