Mastoiditis: Symptoms, Types, Causes and Treatment

Mastoiditis is a serious infection of the mastoid process—the bone located just behind the ear. Although rare today, especially in the age of widespread antibiotics, mastoiditis remains an important complication of middle ear infections, particularly in young children. Recognizing its symptoms, understanding its types and causes, and knowing how it's treated can be life-saving. This comprehensive guide will walk you through everything you need to know about mastoiditis, backed by the latest clinical evidence.

Symptoms of Mastoiditis

Mastoiditis typically announces itself with dramatic and distressing symptoms, especially in children. The infection, which often follows untreated or severe acute otitis media (middle ear infection), can progress rapidly and lead to severe complications if not identified early.

Symptom	Description	Frequency/Prevalence	Sources
Otalgia	Ear pain, often severe	84% of cases	1 3 4 11
Fever	Elevated temperature, sometimes high	Common, esp. in children	2 3 5 11
Retroauricular Swelling	Swelling behind the ear	74% of patients	1 3 4 5
Erythema	Redness over mastoid area	Often with swelling	1 3 4 5
Displaced Pinna	Ear pushed forward/outward	58% of cases	1 3 5
Otorrhea	Ear discharge	Frequently present	4 5 11
Mastoid Tenderness	Pain on pressing mastoid region	Typical finding	4 5
Hearing Loss	Reduced hearing in affected ear	May occur	3 5
Facial Weakness	Facial nerve palsy (complication)	Rare, serious	5 11
Malaise	General sense of being unwell	Systemic symptom	4

Table 1: Key Symptoms of Mastoiditis

Understanding the Symptoms

Mastoiditis symptoms can start subtly but often escalate quickly:

Ear Pain (Otalgia)

• The most common and persistent symptom, often severe and throbbing.
• Children may become irritable or inconsolable due to pain 1 2 3.

Fever and General Illness

• High-grade fever is common, sometimes persisting even after starting antibiotics for an ear infection.
• Accompanied by malaise, lethargy, or overall discomfort 2 4 5.

Swelling and Redness Behind the Ear

• Retroauricular (behind-the-ear) swelling and redness are classic signs.
• The skin may appear shiny, stretched, and warm to the touch 1 3 4.
• Swelling can push the ear outward (displaced pinna), a hallmark finding 1 3 5.

Ear Discharge (Otorrhea)

• Pus or fluid draining from the ear canal is frequently observed, especially if the eardrum ruptures 4 5 11.

Other Symptoms

• Tenderness over the mastoid bone (pain on pressing the area).
• Hearing loss in the affected ear may be noted, particularly if the infection is advanced 3 5.
• Rare but severe complications include facial nerve palsy, vertigo, or neurological symptoms if the infection spreads 5 11.

When to Seek Medical Help

• Persistent pain and fever despite appropriate antibiotic treatment for ear infection.
• New swelling or redness behind the ear.
• Any signs of neurological involvement (facial weakness, confusion, neck stiffness).

Types of Mastoiditis

Not all mastoiditis is the same. The infection can present acutely, chronically, or in less typical forms. Understanding the distinctions is crucial for appropriate management.

Type	Description	Patient Profile/Context	Sources
Acute Mastoiditis	Rapid onset, often after otitis media	Mostly children; <5 yrs	1 3 4 11
Chronic Mastoiditis	Long-standing, smoldering infection	Adults, recurrent cases	1 3
Classical Mastoiditis	Severe, pre-antibiotic era presentation	Rare today, severe course	7
Latent Mastoiditis	Prolonged, subtle presentation	More common post-antibiotics	7
Primary Mastoiditis	Direct mastoid infection (rare)	TB, syphilis, trauma cases	8
Complicated Mastoiditis	With abscesses or CNS spread	Any age, severe disease	5 11 12

Table 2: Types of Mastoiditis

Exploring the Types

Acute Mastoiditis

• Definition: Sudden, severe infection of the mastoid air cells, almost always following acute otitis media (AOM) 1 3 4.
• Who’s affected: Primarily young children, especially under 5 years old 1 2 4.
• Course: Rapid progression, often within days of a middle ear infection.

Chronic Mastoiditis

• Definition: Long-standing inflammation and infection of the mastoid process, typically with less dramatic symptoms.
• Who’s affected: Older children and adults, or those with untreated or recurrent ear infections 1 3.
• Risks: Higher chance of complications like cholesteatoma development.

Classical vs. Latent Mastoiditis

• Classical: Seen before widespread antibiotic use; characterized by aggressive infection, high complication rates, and frequent need for surgical intervention 7.
• Latent: Milder, more prolonged; less common now, but may still occur in partially treated or immunocompromised individuals 7.

Primary Mastoiditis

• Definition: Infection of the mastoid bone without preceding ear infection.
• Causes: Rare, but can result from tuberculosis, syphilis, or direct trauma 8.
• Clinical features: May lack ear discharge or middle ear inflammation.

Complicated Mastoiditis

• Definition: Mastoiditis that leads to local (subperiosteal abscess, facial nerve palsy) or distant (intracranial abscess, meningitis) complications 5 11 12.
• Significance: Requires urgent and aggressive management.

Causes of Mastoiditis

Mastoiditis almost always arises as a complication of middle ear infection, but several factors contribute to its development. Understanding the underlying causes helps clinicians prevent, diagnose, and manage the condition more effectively.

Cause	Description	Common Organisms/Factors	Sources
Acute Otitis Media	Infection of the middle ear	S. pneumoniae, S. pyogenes	1 3 4 10 11
Inadequate Antibiotic Use	Delayed or insufficient treatment	Resistant bacteria	1 9 11 13
Host Factors	Young age, immune compromise	Age <5 yrs, chronic illness	1 2 11
Direct Mastoid Infection	Rare, via trauma or systemic disease	TB, syphilis, trauma	8
Polymicrobial Infection	Multiple bacteria or fungi	S. aureus, H. influenzae, P. aeruginosa, fungi	1 3 9 10 11

Table 3: Causes of Mastoiditis

Delving Into the Causes

Acute Otitis Media (AOM)

• Primary Pathway: Nearly all mastoiditis cases stem from acute middle ear infection.
• Mechanism: Infection spreads from the middle ear to the mastoid air cells, breaking down bone and leading to abscess formation 1 3 4 10.
• Why children? Young children have more horizontal and shorter Eustachian tubes, making spread easier 1 2 11.

Inadequate or Delayed Antibiotic Treatment

• Problem: Incomplete treatment of AOM increases risk; rising antibiotic resistance also plays a role 1 9 11.
• Trend: Despite antibiotics, mastoiditis cases have increased, with more severe and resistant infections reported in recent years 9 13.

Host Factors

• Age: Most cases occur in children under 5, with peak incidence below age 2 1 2 11.
• Immunosuppression: Children with chronic illnesses or immunodeficiencies are at higher risk 1 11.

Pathogens Involved

• Bacteria:
  • Streptococcus pneumoniae: Most common, about 25-28% of cases 1 3 9 10 11.
  • Streptococcus pyogenes, Staphylococcus aureus: Frequently implicated; S. aureus rates are rising 1 3 9 10 11.
  • Others: Haemophilus influenzae, Moraxella catarrhalis, Pseudomonas aeruginosa 1 3 9 11.
• Fungi: Rare, but reported in chronic or immunocompromised cases (e.g., Aspergillus) 1 3.
• Polymicrobial: Mixed infections are not uncommon, especially in chronic or complicated cases 1 3 11.

Rare Causes

• Primary Mastoiditis: Can occur from direct seeding (e.g., trauma, tuberculosis, syphilis) but is exceedingly rare 8.
• Nosocomial/Opportunistic Organisms: Occasionally, especially in hospital-acquired or postoperative cases 3 5.

Treatment of Mastoiditis

Prompt and effective treatment of mastoiditis is essential to prevent serious complications, including permanent hearing loss, facial paralysis, and even death. Treatment strategies have evolved over time, with a growing emphasis on conservative management where appropriate.

Approach	Description	Indications/Notes	Sources
IV Antibiotics	Parenteral, broad-spectrum, high-dose	First-line for uncomplicated	2 4 6 10 11 12 13 14
Myringotomy	Incision in eardrum to drain pus	Adjunct to antibiotics, severe cases	2 6 10 12 13 14
Mastoidectomy	Surgical removal of infected bone	For complications, poor response	6 10 12 13 14
Abscess Drainage	Surgical drainage of subperiosteal abscess	If abscess present	5 12 14
Additional Therapies	Anticoagulants, corticosteroids	As adjuncts in complications	11
Imaging	CT scans to assess extent/complications	If diagnosis uncertain or severe	4 5 10 14

Table 4: Mastoiditis Treatment Strategies

Treatment Details

Intravenous Antibiotics

• First-line: High-dose, broad-spectrum IV antibiotics are the cornerstone of therapy in uncomplicated mastoiditis 2 4 6 10 11 12 13 14.
• Common choices: Third-generation cephalosporins (e.g., ceftriaxone), ampicillin-sulbactam; vancomycin added if MRSA suspected 4 5 10 11.
• Duration: Typically 7–14 days, often followed by oral antibiotics 5.

Myringotomy (with or without Tube Placement)

• Purpose: Relieves pressure, facilitates drainage, and allows better antibiotic penetration 2 6 10 12 13 14.
• Indication: Persistent middle ear effusion, severe pain, or failure to improve with antibiotics alone.
• Outcomes: Comparable cure rates to mastoidectomy in uncomplicated cases 2 13 14.

Mastoidectomy

• When needed: For patients with:
  • Subperiosteal abscess
  • Intracranial extension (e.g., abscess, meningitis)
  • Failure of conservative therapy (no improvement in 48–72 hours)
• Procedure: Removal of infected mastoid bone tissue; more invasive but often lifesaving 6 10 12 13 14.
• Trend: Once routine, now reserved for complicated or refractory cases 10 13 14.

Drainage of Abscesses

• Subperiosteal Abscess: May be managed by incision and drainage, sometimes without full mastoidectomy 5 12 14.
• Intracranial Abscess: Requires neurosurgical intervention in addition to antibiotics 5 12.

Additional Therapies

• Adjuncts: In severe or complicated cases, anticoagulants for vascular complications, corticosteroids for inflammation 11.
• Supportive Care: Pain control, monitoring for complications.

Imaging and Monitoring

• CT Scanning: Used when diagnosis is unclear or to assess for complications. Not always needed in straightforward cases 4 5 10 14.

Outcomes and Follow-Up

• Prognosis: With timely treatment, most children recover fully 2 6 12 13.
• Complications: Delay in treatment increases risk of hearing loss, facial palsy, intracranial spread 5 11 12.

Conclusion

Mastoiditis, though less common due to widespread antibiotic use, remains a critical diagnosis, especially in children with persistent or severe ear infections. Early recognition and intervention are vital for preventing serious complications.

Key Points:

• Mastoiditis often presents with ear pain, fever, swelling, and redness behind the ear, especially in young children 1 2 3 4.
• Most cases are secondary to acute otitis media; prompt and complete treatment of ear infections is essential 1 3 10 11.
• Types include acute, chronic, classical, latent, and rare primary forms; complicated mastoiditis involves abscess or intracranial spread 1 3 7 8 11.
• Streptococcus pneumoniae is the most common pathogen; resistant bacteria are an increasing concern 1 3 9 10 11.
• Treatment typically starts with IV antibiotics and myringotomy, reserving mastoidectomy for refractory or complicated cases 2 6 10 12 13 14.
• Prognosis is excellent with early and appropriate management; delays can lead to severe, even life-threatening, complications 5 11 12.

Staying vigilant for the warning signs of mastoiditis and understanding its management can make all the difference—especially for the youngest and most vulnerable patients.