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Clinical Summary

Mastoiditis is an infection or inflammation of the mastoid air cells often resulting from extension of purulent OM with progressive destruction and coalescence of air cells. Medial sinus wall erosion can cause cavernous sinus thrombosis, facial nerve palsy, meningitis, brain abscess, and sepsis. With the use of antibiotics for AOM, the incidence of mastoiditis has fallen sharply.

Patients present with fever, chills, postauricular ear pain, and otorrhea. Patients may have tenderness, erythema, swelling, and fluctuance over the mastoid process; proptosis of the pinna; erythema of the posterior-superior EAC wall; and otorrhea.

Management and Disposition

Initial evaluation includes a thorough head, neck, and cranial nerve examination. A complete blood count and sedimentation rate may be obtained to establish a baseline for treatment efficacy assessment. Contrasted CT of the head or mastoid sinus may reveal bone erosion and intracranial involvement.

While oral penicillinase-resistant penicillins, amoxicillin-clavulanic acid, 3rd-generation cephalosporins, and the newer macrolides are effective in mild cases of mastoiditis, severe cases require parenteral antibiotics. Mastoiditis requires prompt consultation and close follow-up.


  1. Most patients require admission for parenteral antibiotics to cover S pneumoniae, H influenzae, M catarrhalis, streptococcal species, and S aureus.

  2. Surgical incision and debridement, and possibly mastoidectomy, are reserved for refractory cases.

  3. Chronic mastoiditis describes chronic otorrhea of at least 2 months in duration. It is often associated with craniofacial anomalies.

  4. Consider a branchial cleft cyst in the differential diagnosis with periauricular swelling.


Acute Mastoiditis. Postauricular swelling, redness, and proptosis in a young girl with acute mastoiditis and sinusitis. (Photo contributor: Lawrence B. Stack, MD.)


Acute Mastoiditis. Bone window of a head CT scan which demonstrates fluid in the right mastoid air cells. Maxillary sinus disease is also present. (Photo contributor: Lawrence B. Stack, MD.)

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