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Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL to Hospital (HC4/H/RR) with ENT capability for ALL suspected cases of mastoiditis.
Red flags
- Postauricular swelling, redness, tenderness, or pinna displacement.
- Facial weakness.
- Severe headache, neck stiffness, altered consciousness.
- Vertigo.
- High fever unresponsive to treatment.
Signs and symptoms
- Postauricular (behind the ear) pain, tenderness, swelling, and redness.
- Protrusion of the auricle (pinna pushed downwards and outwards).
- Ear pain (otalgia).
- Fever.
- Ear discharge (otorrhoea) - may increase or reappear after AOM seemed to improve.
- Hearing loss.
- Headache, lethargy, irritability (especially if complications develop).
Risk factors
- Acute Otitis Media (especially recurrent or partially treated).
- Young age.
- Immunodeficiency.
- Cholesteatoma (can predispose to infection spread).
Diagnosis
Clinical assessment
Diagnosis based on clinical findings of postauricular inflammation (swelling, redness, tenderness, pinna displacement) in a patient with current or recent AOM.
Investigations
- Otoscopy: Examine TM (often shows signs of AOM - perforation, bulge, redness).
- Full Blood Count (FBC): Leucocytosis.
- Culture of ear discharge (if present).
- CT Scan (Temporal Bone): Confirms mastoiditis (opacification of air cells, bony erosion), assesses for complications (abscess, sinus thrombosis).
Diagnostic criteria
Clinical signs of postauricular inflammation + Evidence of AOM +/- Confirmation on CT scan.
Differential diagnosis
- Otitis Externa (pain on pinna movement, canal inflammation, no postauricular swelling typical).
- Postauricular lymphadenopathy.
- Cellulitis overlying mastoid (without underlying bone infection).
- Tumour of mastoid (rare).
Management
Non-pharmacological management
- Urgent Hospital Admission.
- Pain relief.
Pharmacological treatment
- IV Antibiotics (High Dose): Cover common AOM pathogens (Strep pneumoniae, H influenzae, Strep pyogenes, Staph aureus).
- - First line: Ceftriaxone 2-4g IV OD (Child: 50-80 mg/kg OD). (LOC: HC4/H)
- - PLUS Metronidazole 500mg IV Q8H (Child: 7.5 mg/kg Q8H) - if anaerobes suspected or severe disease.
- - Alternatives: Ampicillin/Sulbactam, Clindamycin, Vancomycin (if MRSA suspected).
- - Duration: IV until clear improvement, then switch to appropriate oral antibiotics to complete course (often several weeks total).
- Analgesia: Paracetamol, NSAIDs, Opioids if needed.
Monitoring
Monitor clinical signs (fever, pain, swelling), inflammatory markers (WBC, CRP). Monitor for neurological signs (complications). Repeat imaging if needed.
Complications
- Subperiosteal abscess (pus collection under periosteum behind ear).
- Facial nerve palsy.
- Hearing loss (conductive or sensorineural).
- Labyrinthitis / Vestibulitis (vertigo, dizziness).
- Meningitis.
- Brain abscess (temporal lobe, cerebellum).
- Lateral sinus thrombosis.
- Petrositis (infection spread to petrous apex).
Prevention
- Prompt and adequate treatment of Acute Otitis Media.
- Pneumococcal vaccination.
Patient education
- Explanation of mastoiditis as a serious complication of ear infection.
- Need for hospital admission and IV antibiotics.
- Potential need for surgery.
- Importance of completing full antibiotic course.
- Potential complications including hearing loss.
- Follow-up requirements.
Uganda-specific notes
Mastoiditis still occurs due to untreated or partially treated AOM. Requires high index of suspicion and prompt referral. Ceftriaxone is common IV antibiotic choice. Access to CT scan and mastoid surgery limited to referral hospitals.
Surgical Management
- Myringotomy +/- Grommet Insertion: May be done to drain middle ear effusion.
- Cortical Mastoidectomy: Surgical drainage of infected mastoid air cells. Indicated for: Subperiosteal abscess, Lack of improvement with IV antibiotics after 48-72h, Intracranial complications.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.1.6