Mastoiditis in an immunocompetent adult.

Abstract: A 20-year-old white male presented to the family practice department with a 1-month history of right ear pain and loss of hearing. During the month, he had been seen in emergency rooms twice and also by his dentist. He had been treated with pain medications, tooth extraction, and finally, antibiotics. On presentation to the clinic, his right mastoid area showed erythema, tenderness, and swelling that displaced the pinna. He was immediately referred to the otolaryngology department. Imaging studies confirmed coalescent mastoiditis and subperiosteal abscess. He was taken to surgery, where he underwent cortical mastoidectomy and right pressure equalization tube placement. Intraoperative and postoperative intravenous cefotaxime was given. Recovery was complete and uneventful.

Key Words: immunocompetent adult, mastoiditis, otitis media, subperiosteal abscess

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The advent of antibiotic treatment of otitis media has markedly reduced the incidence of mastoiditis. However, mastoiditis is still seen in a small number of patients and still produces serious complications in some. Most of these patients are very young or are immunocompromised. The following is a report of acute mastoiditis with subperiosteal abscess in an otherwise healthy adult male.

Case Report

A 20-year-old white male was referred for evaluation of a 1-month history of right ear pain. He had been seen twice in emergency rooms, had a right maxillary tooth extracted without improvement, and had received 1 g of ceftriaxone intramuscularly the day before he presented to our clinic. He stated that his hearing was decreased in his right ear, but he had not been running a fever or having drainage from his ear. His medical history was significant for having had pressure equalization (PE) tubes placed during his childhood. He smoked five cigarettes per day but was otherwise very healthy.

Physical examination revealed an alert adult male with his right ear protruding 90 degrees from his head. His right post auricular region was erythematous, edematous, and tender. His right external ear canal was clear, with an opaque tympanic membrane. His left external ear canal was clear, with an intact tympanic membrane and a clear middle ear space. His neurologic examination was normal, other than decreased hearing in the right ear. He had a well-healing right maxillary dental extraction site.

Computed tomography scan of the temporal bones showed significant diffuse soft tissue swelling along the right aspect of the face and temporal bone with opacification of the middle ear and mastoid air cells on the right. There was also suggestion of some destruction of septal walls within the right mastoid air cells. An area of minimal loss of definition along the internal wall of the calvarium could be appreciated.

The patient was given 2 g cefotaxime intravenously after consultation with an infectious disease colleague, and the patient was taken to the operating room immediately for a simple mastoidectomy with PE tube placement for coalescent mastoiditis. In the operating room, he was found to have a subperiosteal abscess superficial to the mastoid cortex. Cultures grew 1 + microaerophilic streptococcus. The mastoid cavity contained purulence and copious granulation tissue, with no dehiscence of the tegmen. Granulation tissue filled the middle ear and was debrided. After a Penrose drain was placed in the depths of the wound, the postauricular incision was closed. A PE tube was placed in the right tympanic membrane with some difficulty secondary to bleeding.

After surgery, the patient was treated with 2 g cefotaxime intravenously every 8 hours and did well. He had fever to 101[degrees]F the first postoperative day. The drain was removed the second postoperative day. The patient was discharged on the third postoperative day, with arrangements for 2 weeks of intravenous ceftriaxone. One week after surgery, he was seen in the otolaryngology department and was healing well. At his 2-week post-operative visit, the tenderness had essentially resolved. At his 6-week postoperative visit, he had a well-healed postauricular incision and the PE tube was in place and patent. His audiogram revealed a 20-dB conductive loss at 250 Hz in the right ear with air/bone closure at 1,000 Hz and bone scores within normal limits bilaterally. His speech reception threshold was 0 dB bilaterally, with 96% discrimination in the right ear and 100% in the left ear. He has since been lost to follow-up.

Discussion

In the early 20th century, as many as half of all patients with otitis media had development of mastoiditis. By 1960, the incidence had fallen to less than 0.5%. (1) As a result, mastoiditis is virtually unknown to many physicians today. However, several series have shown that mastoiditis still occurs in pediatric patients in the United States and elsewhere, generally because of antibiotic resistance (2) or lack of antibiotic treatment. (3) Mastoiditis may be the presenting problem in middle ear infection, especially in very young children. (4) In one series of patients with mastoiditis, specific findings of post-auricular pain, swelling, and redness of the mastoid were found in fewer than half of the patients. (5) Clearly, when treating pediatric patients for otitis media, one should be aware of the possibility of mastoiditis, particularly in patients with significant ear pain and in those whose otitis does not resolve promptly. This case illustrates that mastoiditis can also occur in an otherwise healthy adult.

Conclusion

The use of antibiotics to treat otitis media has reduced the incidence of mastoiditis to very low levels. However, mastoiditis is still a complication of middle ear infection in both children and adults. It can occur early in the course of otitis media, and antibiotic treatment does not always prevent mastoiditis. Although mastoiditis is seen more in very young patients and in those who are immunocompromised, it does occur in patients with no underlying disease. Mastoiditis should be considered in the differential diagnosis of all patients with severe ear pain.

So many people, so little thought.
--Anthony Weir

Acknowledgment

Literature review assistance was provided by the Ochsner Medical Library staff.

Accepted October 5, 2004.

References

1. Spiegel JH, Lustig LR, Lee KC, et al. Contemporary presentation and management of a spectrum of mastoid abscesses. Laryngoscope 1998;108:822-828.

2. Tarantino V, D'Agostino R, Taborelli G, et al. Acute mastoiditis: a 10-year retrospective study. Int J Pediatr Otorhinolaryngol 2002;66:143-148.

3. Van Zuijlen DA, Schilder AG, Van Balen FA, et al. National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media? Pediatr Infect Dis J 2001;20:1012-1013.

4. Linder TE, Briner HR, Bischoff T, Prevention of acute mastoiditis: fact or fiction? Int J Pediatr Otorhinolaryngol 2000;56:129-134.

5. Cheng MF, Chiou CC, Hsieh KS, Mastoiditis: a disease often overlooked by pediatricians. J Microbiol Immunol Infect 2000;33:237-240.

RELATED ARTICLE: Key Points

* Mastoiditis has become relatively rare, with antibiotic treatment of otitis media.

* Mastoiditis still occurs in immunocompetent patients, both adults and children.

* Mastoiditis should be considered in all severe or intractable cases of ear pain or otitis.

Katharine C. Rathbun, MD, MPH, and Mary S. Kendall, MD

From Ochsner Clinic Foundation, Baton Rouge, LA.

No financial support was received in preparing this case report.

The authors have no proprietary interest in any drug, device, equipment, or other items mentioned in the report.

Reprint requests to Dr. Katharine C. Rathbun, Ochsner Clinic Foundation, 9001 Summa Ave., Baton Rouge, LA 70809. Email: [e-mail]