Acute mastoiditis. Causes, symptoms and treatment

Otolaryngologist for adults and children

Son of the gods

Stanislav Vladimirovich

25 years of experience

Otorhinolaryngologist of the highest category, Candidate of Medical Sciences, member of the European Rhinological Society (European Rhinologic Society)

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An infection that has entered the body can manifest itself in the most unexpected way. So, with acute otitis media, the patient sometimes develops a concomitant disease - mastoiditis of the ear. This is the name for inflammation of the mastoid process of the temporal bone, which has an infectious etiology. The symptoms noted during the development of the inflammatory process are characteristic of any type of infectious disease: pain and redness of the skin behind the ear, painful pulsation, increased temperature, swelling of the tissues and decreased hearing resulting from swelling. The diagnosis can be made based on a visual examination: upon palpation, a compaction in the area of ​​the temporal bone caused by suppuration can be clearly felt. You can cope with the disease conservatively or surgically, blocking the development of purulent foci and destroying pathogenic microorganisms with the help of antibiotics.

Etiology of the disease

The mastoid process of the temporal bone is located behind the auricle. Its internal structure consists of many interconnected cells with dense partitions. The following features of the bone structure of the appendix are considered normal:

• with a pneumatic structure - many large air cells;
• with a diploetic structure - small cells filled with bone marrow;
• with a sclerotic structure - an almost complete absence of cells.

The development of left-sided or right-sided mastoiditis largely depends on the structure of the mastoid process. The fewer cells, the lower the likelihood of inflammation and its spread throughout the bone tissue structure. More often, mastoiditis with inflammation is observed in patients with pneumatic bone structure. Its development is caused by the spread of infection from the tympanic cavity in acute otitis media or chronic purulent otitis. It is dangerous to neglect the pathology due to the possible spread of suppuration to adjacent tissues and complete hearing loss.

Causes

Depending on the causes of otitis media and its complications, the following types of mastoiditis are distinguished:

• otogenic – caused by the spread of infection to the parotid tissues in the absence of timely treatment of acute otitis. The causative agents are staphylococci, pneumococci, streptococci or influenza bacillus. The development of the inflammatory process is facilitated by a small hole in the eardrum, disruption of the outflow of pus and its accumulation, and closure of the ear opening with granulation tissue;
• hematogenous - a type of disease that develops as a secondary infection in syphilis, tuberculosis and other infectious diseases;
• traumatic form of mastoiditis - is the cause of damage to the mastoid process due to impact, injury or traumatic brain injury. The accumulation of blood in the area of ​​damage and disruption of its drainage process serves as a favorable environment for the development of infection.

Activation of the inflammatory process is facilitated by:

• weakening of the body's immune defense;
• pathologies of the nasopharynx, the patient’s history of chronic diseases;
• changes in the structure of the auricle after illnesses;
• high virulence (degree of pathogenicity) of the infection that has entered the body.

Classification of mastoiditis

All types of mastoiditis are divided into primary and secondary. According to another classification, hematogenous, otogenic and traumatic mastoiditis are distinguished. As for the classification of mastoiditis at the stage of the inflammatory process, true (or proliferative-alternative) and exudative mastoiditis are distinguished. There are also typical and atypical forms of mastoiditis. Unlike the typical one, the atypical (or latent) form has a slow and sluggish course, without any particularly pronounced symptoms, so characteristic of mastoiditis. Experts also distinguish a special group of apical type mastoiditis. These include Orleans mastoiditis, Bezold mastoiditis and Mouret mastoiditis.

Pathogenesis. Stages of disease development

The initial stage of the disease is called exudative. The development of chronic mastoiditis begins with inflammation of the mucous cells of the mastoid process with the simultaneous development of periostitis (inflammation of the periosteum) and the accumulation of exudate in the bone cavity. Swelling of the tissues, together with the accumulation of fluid, blocks the communication between the cells and the passage between the tympanic cavity and the mastoid process, thereby “clogging” the infectious process. Due to impaired ventilation in the cells, the air pressure in them drops, and under the influence of internal pressure, transudative fluid from the blood vessels begins to flow into the affected area. Mixed with pus, it quickly fills all the cells of the mastoid process. The first stage of the disease lasts about 10 days, in children – up to 6 days.

The second stage is proliferative-alterative. Purulent inflammation spreads to the bone walls and septa, contributing to the development of osteomyelitis. The partitions are destroyed, and one cavity is formed inside the bone tissue, filled with purulent contents. The disease takes on a typical or atypical form. The second is characterized by a sluggish course and mild symptoms.

Symptoms in adults

The appearance of signs of mastoiditis can be observed simultaneously with signs of otitis, but is more often observed 7-10 days after the manifestation of the underlying disease. In adults, the complication makes itself felt by increased body temperature, headache, sleep disturbance, and a state of general intoxication. The prevailing complaints from patients include pulsation and noise in the ear, hearing loss, and sharp pain when trying to touch the skin near the auricle. The pain radiates along the nerve fibers to the upper jaw and temporal region of the head. At the same time, there is a copious outflow of purulent contents from the ear canal, redness of the area behind the ear, and protrusion of the auricle caused by swelling of adjacent tissues. Breakthrough of the purulent cavity is accompanied by severe pain, thrombosis of blood vessels and the development of necrosis of the periosteum with the formation of a percutaneous fistula.

Consequences

The most serious complications of mastoiditis are lesions of the facial nerve:

• facial asymmetry occurs
• the corner of the mouth or eye moves downwards,
• the face becomes like a mask,
• the eyelid does not close well.

The second dangerous complication of mastoiditis is the breakthrough of pus into the cranial cavity with the formation of inflammation of the meninges or brain matter. This causes general symptoms of infection:

• fever with inflammatory changes in the blood,
• sleep and appetite disturbances,
• nausea and even vomiting,
• refusal to eat due to ear pain.

Complications

In advanced cases, in the absence of timely medical care, the acute development of one- or two-sided mastoiditis can lead to:

• neuritis of the facial nerve;
• thrombophlebitis;
• purulent mediastinitis, when pus penetrates into the space of the cervical spine;
• brain abscess, encephalitis;
• damage to the eyeball, development of phlegmon or endophthalmitis;
• sepsis, retropharyngeal process.

When to see a doctor

The first signs of otitis or mastoiditis require timely examination by a specialist, qualified treatment and constant monitoring. You should stop trying to self-medicate and contact an otolaryngologist for additional diagnostics and development of a treatment course.

Prevention of mastoiditis

If the symptoms and treatment of mastoiditis are clear, then it is necessary to talk about the prevention of this disease. Prevention, as a rule, is based on the prevention of otogenic mastoiditis, which is possible thanks to the timely diagnosis of inflammatory processes in the middle ear. Proper treatment of otitis media and timely paracentesis of the eardrum are also part of the prevention of mastoiditis. Promptly eliminating foci of infection and carrying out correct therapy will help prevent possible mastoiditis in a timely manner. Great importance in prevention is given to the quality of performance of the immune mechanisms of the human body. The latter is achieved by leading a healthy lifestyle and following the basics of proper nutrition.

Diagnostics

It is possible to make an accurate diagnosis by visually examining the area behind the ear of the patient’s head. Difficulties in diagnosis can only be caused by atypical mastoiditis, when the symptoms are either completely absent, or rather mild, or similar to the manifestations of a number of infectious diseases. Additional studies of instrumental and laboratory diagnostics include otoscopy, microotoscopy, bacteriological culture of ear discharge, radiography and computed tomography. The image of the temporal region clearly visualizes veiled cells, “clogged” with purulent contents, and barely visible septa. If necessary, a neurosurgeon, dentist, ophthalmologist and other highly specialized doctors are involved in the diagnosis.

Treatment in adults

The treatment course is developed taking into account the etiology of the disease and its complexity, the patient’s age and the general condition of the body. As a drug therapy, a course of antibiotics is prescribed to stop the inflammation and destroy the causative agents of mastoiditis. Antihistamines, compounds for stimulating the immune system, and anti-inflammatory medications can help relieve painful symptoms and signs of swelling in acute purulent mastoiditis. To remove purulent contents in case of mastoiditis, sanitizing or general cavity surgery is used in the behind-the-ear area of ​​the head. Surgical opening of the appendix allows the cells to be cleared of pus and drainage performed to restore the bone structure. Through the opening of the middle ear, purulent exudate is removed by washing.

Clinical picture

In acute mastoiditis, clinical manifestations are both general and local.
For typical forms of mastoiditis, the main subjective symptom is ear pain, which appears at the end of the third week of acute otitis media. It occurs if you press on the platform of the mastoid process or on its apex. Patients experience hearing loss, which develops as a type of sound conduction disorder. But the main and objective manifestation of this disease is copious purulent discharge from the ear, as well as overhanging of the posterior-superior wall of the bony part of the external auditory canal. There is hyperemia (redness) and infiltration of the eardrum, which is why it is not always possible to find a perforation of the eardrum. In acute mastoiditis, one very characteristic symptom is observed - almost immediately after using the toilet or washing the external auditory canal, it very quickly fills with pus again. Most often, pus breaks out on the mastoid area. A fistula forms in the bone, and through it, liquid pus penetrates under the periosteum of the mastoid process and peels it off along with the skin, forming a subperiosteal abscess. In this case, there is a displacement of the auricle forward and downward, and the line of its attachment is smoothed out. In the area behind the ear, the skin is hyperemic and shiny; upon palpation, fluctuation phenomena are observed. A subperiosteal abscess can form at a variety of times.

Friends! Timely and correct treatment will ensure you a speedy recovery!

In some cases, pus breaks into the area of ​​the zygomatic process and then zygomatitis develops. In this case, spontaneous pain and soreness are observed when pressing on the area of ​​the zygomatic process, the soft tissues of the affected area swell, and the auricle moves outward and downward. Quite often, all these phenomena occur with an intact (undamaged, uninvolved in the process) mastoid process.

If pus breaks through the inner wall of the apex of the mastoid process, then Betsoldovsky mastoiditis develops, which is characterized by deep pus, which is located under the muscles of the neck.

Apical mastoiditis of Orleans develops if pus breaks through to the outer surface of the apex of the mastoid process and the formation of a fluctuating infiltrate is observed at the attachment site of the sternocleidomastoid muscle. In this case, pronounced changes are observed in the area behind the ear, which are inflammatory in nature, and upon palpation severe pain occurs.

Moore's mastoiditis develops if pus breaks out in the area of ​​the digastric fossa, which is located on the anterior-inferior surface of the mastoid process. The pus then penetrates into the posterior parotid space, where the internal jugular vein is located.

If pus breaks into the area of ​​the scales (squama) of the temporal bone, the development of squamite is observed. If such a process occurs through the cells of the pyramid (petrous part) of the temporal bone, petrositis occurs, which is characterized by a triad of Gradenigo symptoms: first acute otitis media develops, then trigeminitis (inflammation of the trigeminal nerve), and then paresis or paralysis of the abducens nerve.

Atypical or latent mastoiditis should be included in a special group. With them, symptoms characteristic of the typical form of mastoiditis are absent. They proceed very slowly and sluggishly. The purulent process in the mastoid process occurs without the formation of exudate in the middle ear. Also, with this form of the disease there is no severe fever and pain when pressing on the mastoid area. Only in the later stages of the disease may pain appear on palpation in the area behind the ear.

Atypical mastoiditis is characterized by certain microsymptoms, which are manifested by mild general and local symptoms that do not cause a deterioration in the patient’s condition, and almost no changes are observed in the blood. Patients complain of hearing loss, which can manifest itself in varying degrees of severity, and congestion in the affected ear. In some cases, there is pain in the mastoid area, as well as headaches from the affected ear. The otoscopic picture is quite diverse: there is a change in the color of the eardrum, as well as a pronounced and widespread infiltration. In some cases, you can see that the posterior-superior sections of the eardrum are thickened, and the angle between the membrane and the posterior-superior wall of the ear canal is smoothed. The integrity of the eardrum is not compromised.

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