Chronic Mastoiditis

Chronic mastoiditis is persistent infection and inflammation of the mastoid air cells and middle ear, usually associated with chronic suppurative otitis media, tympanic membrane perforation or cholesteatoma.

• Chronic suppurative otitis media affects 1 to 4 percent of children in many African settings, where access to care is limited.
• Two types: tubotympanic (safe, mucosal) with a central perforation and mucopurulent discharge, and atticoantral (unsafe) with cholesteatoma, granulation and bone erosion.
• Common organisms: Pseudomonas aeruginosa, Staphylococcus aureus, Proteus, Klebsiella and anaerobes.
• Tuberculous mastoiditis is a rare, painless cause.
• Complications can be life-threatening, and cholesteatoma is the most dangerous cause.

Painless discharge and hearing loss dominate.

• Chronic or intermittent ear discharge for more than 6 weeks, often foul-smelling, with conductive hearing loss.
• Otoscopy: central perforation (safe type) or marginal or attic perforation with debris, keratin and granulation (unsafe type).
• Pain, headache, fever, postauricular swelling and vertigo suggest complications.
• Facial weakness, vertigo, sensorineural loss, meningism or fever with spiking course indicate spread.
• Differential diagnosis: chronic suppurative otitis media without mastoid involvement, chronic otitis externa, tuberculous otitis, granulomatosis with polyangiitis, Langerhans cell histiocytosis, cholesteatoma and malignancy.
• Complications: cholesteatoma, mastoid abscess, labyrinthine fistula, facial palsy, sensorineural loss, meningitis, brain abscess, sigmoid sinus thrombosis and lateral sinus thrombosis.

Examination, culture, audiometry and imaging are needed.

• Otomicroscopy after cleaning: perforation, cholesteatoma, granulation, polyp.
• Culture of discharge for aerobes, anaerobes and (if indicated) mycobacteria and fungi.
• Pure tone audiometry: conductive or mixed loss.
• High-resolution temporal bone computed tomography: opacified mastoid, scutum erosion, ossicular erosion, tegmen dehiscence, labyrinthine fistula. MRI with diffusion-weighted imaging for cholesteatoma or intracranial complications.
• Full blood count, C-reactive protein, blood culture in febrile patients.
• HIV test and tuberculosis assessment in resistant disease.

Control infection, then repair surgically if needed.

• Supportive: keep the ear dry, aural toilet by suction or dry mopping (avoid irrigation if perforated), and avoid water entry.
• Pharmacological: topical quinolone drops (ciprofloxacin 0.3 percent, 3 to 5 drops twice daily for 7 to 14 days) after aural toilet; they are safe with perforation. Avoid aminoglycoside drops in perforation. Topical boric acid or acetic acid powder or drops for resistant cases. Systemic antibiotics (oral ciprofloxacin 500 mg twice daily in adults for 7 days, or intravenous ceftazidime 2 g every 8 hours or piperacillin-tazobactam 4.5 g every 8 hours for acute exacerbation) only for acute infection, cellulitis, or complications.
• Procedures: tympanoplasty for dry safe-type perforation; canal wall up or canal wall down mastoidectomy for cholesteatoma, persistent discharge, or complications; ossiculoplasty for hearing reconstruction. Emergency surgery for intracranial complications.
• Special groups: children with recurrent disease need hearing rehabilitation, with hearing aids. Immunocompromised patients need cultures and tuberculosis tests.
• Red flags: vertigo, facial palsy, headache, fever, meningism, postauricular swelling, foul discharge with cholesteatoma, and sensorineural hearing loss.
• Follow-up: review every 3 to 6 months, with audiometry. Post-surgical surveillance for cholesteatoma recurrence for at least 5 years.