ENT: Mastoiditis

 

 

Mastoiditis

Definition: Inflammation of the mucosal lining of mastoid antrum and mastoid air cells. Infection has spread from mucosal lining to the bone

Incidence:

The reported rate in the past 20 years has been 0.24%

The rate of intracranial complications due to matsoiditis 4-16.6%

Types: 

Acute mastoiditis

Masked / latent mastoiditis

Acute mastoiditis

            Inflammation of mucosal lining of mastoid antrum and mastoid air cells.

ETIOLOGY & RISK FACTORS:

·         Streptococcus    

·         Acute and chronic otitis media

·         Staphylococcus

·         Poor nutrition

·         Pneumococcus  

·         Associated systemic disease- diabetes, blood borne diseases

·         Hemophilus influenza             

·         Pseudomonas  

·         Penetrating trauma

 

Pathophysiology

Acute infection of mastoid air cells

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Persistent hyperaemia, congestion & edema of mucous membrane of the air cells + osteitis

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obstruction of aditus

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Purulent exudate in air cells

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Pressure effect

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Venous stasis

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Absorotion of Ca++ 

Hvoeraemic decalcification

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Local acidosis

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Breaking down of the partition of air cells

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Tract down to various sites

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Abscess

(post auricular abscess, pharyngeal abscess, Benzold’s abscess, zygomatic abscess, Luc’s abscess, apical abscess)

 

 Clinical Menifestation

Symptoms:

·         Pain and swelling in the mastoid region

·         Fever

·         Ear discharges: mucopurulent Deafness: conductive type

 

Signs:

Mastoid tenderness: apply pressure on mastoid area patient will complaints of pain

Sagging of posterior-superior meatal wall: it is due to the inflammation of bony wall between antrum and deep part of meatal wall.

Perforation of tympanic membrane: there will be Sinall perforation in the pars tensa.

Swelling over mastoid: initially there will be oedema of periosteum, later retroauricular sulcus becomes obliterated and pinna is pushed forward and downward.

Hearing loss: conductive type hearing loss

General findings: patient will feel sick and have low grade fever, and in children fever will be high

 

Diagnosis

·         Complete Blood Count- shows leucocytosis

·         ESR is usually raised

·         Ear swab for culture and sensitivity

·         Radiographic evaluation: Inflammation and fluid within the air spaces/ cloudiness

 

Medical Management

Antibiotic

·         Intravenous antibiotic therapy should be maintained for at least 24-48 hrs after the resolution of symptoms

·         Then followed with oral antibiotic for 2 weeks

·         It should be based on the culture and sensitivity report

Surgical management

1.Incision and drainage of the pus

2.Mastoidectomy:

·         Radical mastoidectomy: Radical Mastoidectomy is a procedure to eradicate disease from the middle ear and mastoid without any attempt to reconstruct hearing.

·         Modified Radical Mastoidectomy: It is a modification of radical mastoidectomy where as much of the hearing mechanism as possible is preserved.

·         Cortical Mastoidectomy (Also known as schwartze procedure) - Removal of Mastoid air cells is undertaken without affecting the middle ear.

 

Complication:

·         Subperiosteal abscess                   

·         Facial paralysis     

·         Extradural abscess            

·         Meningitis 

·         Brain abscess                    

·         Petrositis                           

·         Labrynthitis

 

Nursing management:

Pre operative care:

·         Before surgery an audiogram and tympanogram are obtained to assess the hearing acuity

·         Knowledge about the procedure and psychological readiness

·         Educate about the duration of procedure, post op duration of hospital stay

Post op care:

·         Positioning: operated ear should be up for several hours after surgery

·         Nose blow should be avoided, if at all doing it should be gentle

·         The client should sneeze or cough with the open mouth

·         Participation in water sports or activities in water are prohibited

·         Change the cotton ball in ear daily as prescribed  

·         Keep ear dry for 4 to 6 weeks after surgery

 

Masked (Latent) Mastoiditis:

It is a condition of slow destruction of mastoid air cells but without the acute signs and symptoms often seen in acute mastoiditis

ETIOLOGY: Inadequate antibiotic therapy in terms of dose, frequency, and duration of administration In case of acute otitis media

Clinical Manifestation:

·         Mild pain behind year

·         Tympanic membrane appears thick

·         Slight tenderness over the mastoid

·         Audiometry shows conductive hearing loss

·         X-ray mastoid shows clouding of the air cells

TREATMENT: cortical mastoidectomy with full doses of antibiotic

Patient teaching:

·         Teach patient and family how to change dressing

·         Tel them to avoid wetting of the dressing

·         Teach about the instillation of ointment or ear drops

·         Regular follow-up