What are the key aspects of mastoiditis to know for the Physician Assistant National Certifying Examination (PANCE)?

From the Guidelines

Mastoiditis is a serious complication of acute otitis media that requires prompt recognition and aggressive management to prevent significant morbidity and mortality, and for the PANCE exam, it is essential to understand its pathophysiology, clinical presentation, diagnosis, and treatment. Mastoiditis occurs when infection spreads from the middle ear to the mastoid air cells, typically as a complication of untreated or inadequately treated acute otitis media 1. Key clinical features include postauricular erythema, tenderness, swelling, and outward protrusion of the auricle. Patients typically present with fever, ear pain, and hearing loss. Diagnosis involves physical examination findings, otoscopy showing a bulging tympanic membrane or perforation, and imaging with CT scan to evaluate the extent of infection and potential complications, as recommended by the ACR Appropriateness Criteria for headache in children 1.

Key Aspects of Mastoiditis

• Clinical presentation: postauricular erythema, tenderness, swelling, and outward protrusion of the auricle, fever, ear pain, and hearing loss
• Diagnosis: physical examination findings, otoscopy, and imaging with CT scan
• Treatment: aggressive management with IV antibiotics that cover common pathogens, including Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and anaerobes, with initial empiric therapy typically including ceftriaxone and clindamycin or ampicillin-sulbactam 1
• Surgical intervention: indicated for cases that fail to respond to antibiotics within 24-48 hours, have intracranial complications, or show bone destruction on imaging

Management and Treatment

• Initial empiric therapy typically includes ceftriaxone 1-2g IV daily plus clindamycin 600-900mg IV every 8 hours, or ampicillin-sulbactam 3g IV every 6 hours 1
• Surgical intervention with mastoidectomy is indicated for cases that fail to respond to antibiotics within 24-48 hours, have intracranial complications, or show bone destruction on imaging
• Potential complications include facial nerve paralysis, labyrinthitis, meningitis, brain abscess, and sigmoid sinus thrombosis, and early recognition and treatment are essential to prevent these serious sequelae 1

Imaging and Diagnosis

• CT scan is recommended for evaluating the extent of infection and potential complications, especially in cases with suspected intracranial infection or mastoiditis 1
• Laboratory studies often reveal leukocytosis and elevated inflammatory markers, and physical examination findings and otoscopy are essential for diagnosis 1

From the Research

Key Aspects of Mastoiditis for PANCE Exam

• Definition: Acute mastoiditis is a suppurative infection of the mastoid air cells, often associated with otitis media 2.
• Presentation: Common symptoms include pain, fever, postauricular edema, and an abnormal-appearing tympanic membrane 3, 4, 2.
• Risk Factors: History of antecedent acute otitis media, elevated white blood cell count, proptosis of the auricle, and fever on admission are risk factors for surgical intervention 3.
• Diagnosis: Laboratory analysis may reveal evidence of systemic inflammation, and computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the diagnosis is unsure 2.
• Treatment: Includes antibiotics such as ampicillin-sulbactam or ceftriaxone, as well as otolaryngology consultation 2.
• Complications: May include subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures 2, 5.

Patient Evaluation

• Physical examination: Should include assessment of the tympanic membrane, postauricular area, and external auditory canal 3, 4, 2.
• Laboratory tests: May include white blood cell count and other inflammatory markers, but normal results should not be used to exclude the diagnosis 2.
• Imaging studies: CT of the temporal bones with intravenous contrast may be necessary to confirm the diagnosis and demonstrate complications 2.

Management and Prevention

• Antibiotic therapy: Should be initiated promptly, with coverage for common bacteria such as Streptococcus and Staphylococcus 2.
• Surgical intervention: May be necessary in cases of complicated acute mastoiditis, such as subperiosteal abscess or intracranial complications 3, 6, 4.
• Follow-up care: Patients should be closely monitored for signs of complications and recurrence, and receive prompt treatment if necessary 2, 5.