FFinalistSouthampton · 2027
ENT
AKT · ENT/Ear & hearing

Mastoiditis

Suppurative infection of the mastoid air cells (AOM complication)

Overview

A suppurative complication of acute otitis media in which infection spreads to the mastoid air cells. Post-auricular swelling, erythema and tenderness PUSHING THE PINNA FORWARD/down in an unwell child — a clinical emergency needing admission, IV antibiotics, and often surgery.

Recognise

  • Recent/current AOM now with post-auricular (behind-the-ear) swelling, redness and tenderness
  • The pinna is pushed FORWARD and DOWNWARD; loss of the post-auricular crease; systemic upset/fever
  • A bulging or perforated drum on the affected side

Red flags

  • Intracranial spread (meningitis, sigmoid sinus thrombosis, abscess), facial nerve palsy, or a subperiosteal abscess → urgent imaging + surgery

Differentials & how to tell them apart

Severe otitis externa with pinna cellulitiscanal-centred with intact mastoid; mastoiditis pushes the pinna forward with post-auricular swelling
Post-auricular lymphadenopathydiscrete mobile node, well child, no protruding pinna
Infected sebaceous cystlocalised, no preceding AOM or systemic upset
Mastoiditis — postauricular swelling, protruding pinna

Mastoiditis — postauricular swelling, protruding pinna

Jojo / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Clinical diagnosis; bloods (raised inflammatory markers), blood cultures; CT temporal bones if abscess/intracranial complication suspected. Urgent ENT.

Management

Admit for IV antibiotics + urgent ENT (myringotomy ± mastoidectomy if abscess)

  1. 1Admit urgently; IV broad-spectrum antibiotics; urgent ENT assessment. Myringotomy (± grommet) to drain the middle ear.Gate: Post-auricular swelling pushing the pinna forward in a child with AOM is MASTOIDITIS → admit for IV antibiotics, NOT outpatient oral antibiotics; a subperiosteal abscess or intracranial sign mandates CT + surgery
  2. 2Subperiosteal abscess, intracranial complication, or no improvement → cortical mastoidectomy; image (CT) and treat complications.
IV broad-spectrum antibiotics — admit and start promptly (e.g. IV ceftriaxone)
Myringotomy ± grommet — drain the middle ear
Cortical mastoidectomy — if abscess or failure to improve

Key points

The pinna pushed forward with post-auricular swelling is the recognition sign. It is the classic suppurative complication of AOM and an admission, not an outpatient problem.

Monitor & prognosis

Inflammatory markers, neurology (intracranial spread), response to IV antibiotics.

Good with prompt treatment; complications can be serious.

Source: NICE CKS; ENT UK