ENT

Mastoiditis

Acute mastoiditis is serious infection extending from the middle ear into the mastoid air cells; a painful red post-auricular swelling with pinna displacement is an ENT emergency because infection can form an abscess or spread to the facial nerve, venous sinuses or intracranial space.

In a nutshell

Mastoiditis is serious infection extending from the middle ear into the mastoid. The classic finding is a tender, red post-auricular swelling with the pinna pushed outwards and loss of the post-auricular crease. Treat it as an ENT emergency: admit, start IV antibiotics using current age- and allergy-specific local guidance, assess for complications, image selectively and drain the middle ear/mastoid when indicated.

Classic presentation

A child with recent acute otitis media develops fever, worsening otalgia and a tender red swelling behind the ear that pushes the pinna outwards and erases the post-auricular crease.

Key points

The combination of post-auricular swelling/tenderness and pinna displacement is the high-yield clinical clue.
A normal tympanic membrane makes acute mastoiditis less likely; examine the ear and mastoid carefully.
Suspected mastoiditis needs emergency ENT/hospital assessment and prompt IV antibiotics; use BNF/BNFc and local microbiology guidance for the regimen.
CT/MRI is for complications, uncertainty or poor response and must not delay initial treatment.
Myringotomy, drainage or mastoidectomy may be needed for collections, bony disease, complications or treatment failure.
Facial palsy, meningism, neurological change, severe headache, seizures, vertigo or deterioration are emergency complication signs.

First-line investigation

Immediate clinical examination with otoscopy and ENT assessment; CT temporal bones or MRI/venous imaging if complicated, uncertain or not improving.

Management

Treat as an ENT emergency

Refer urgently to hospital/ENT, monitor and manage sepsis, hydration and pain; admit when mastoiditis or a complication is suspected.^2,3,1

Give IV antibiotics and assess the ear

Start IV antibiotics promptly using current BNF/BNFc and local ENT/microbiology guidance, with allergy and previous-culture checks; perform otoscopy and assess facial, neurological and vestibular function.^1,4,5

Look for abscess or intracranial spread

Facial palsy, meningism, severe headache, altered consciousness, seizures, vertigo, fluctuance or deterioration needs urgent complication-directed imaging and specialist input.^3,2,1

Drain the source when required

ENT may perform myringotomy/grommet or mastoid drainage/mastoidectomy for a collection, bony disease, major complication or failure to improve on appropriate IV antibiotics.^1,4

Review response and safety-net

Agree IV-to-oral step-down, total duration, discharge and ENT/audiology follow-up with the treating team; safety-net for recurrent fever, swelling, headache, vomiting, drowsiness, facial weakness or neurological symptoms.^1,4

Exam traps

Do not treat a proptosed ear with a tender post-auricular swelling as uncomplicated otitis media.
Do not wait for CT before antibiotics and senior ENT involvement when the clinical picture is convincing.
Do not use an adult antimicrobial dose for a child or copy a local regimen without checking BNF/BNFc, allergy and microbiology context.
A normal tympanic membrane makes mastoiditis less likely but does not replace a full assessment when the patient is very unwell.
Facial palsy or meningism signals a complication, not simply a more painful ear infection.

Illustrations

Acute mastoiditis with a protruding earA clinical photograph showing post-auricular swelling and erythema pushing the pinna forwards and outwards, with loss of the post-auricular crease.B. Welleschik, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.