What are the symptoms of Mastoiditis?

Symptoms of Mastoiditis

Mastoiditis presents with a characteristic constellation of symptoms that distinguish it from uncomplicated acute otitis media: pain (98% of cases), fever (83%), postauricular swelling and erythema (76%), and protrusion of the auricle, along with an abnormal tympanic membrane (88%) and narrowed external auditory canal (80%). 1

Cardinal Presenting Symptoms

Primary Otologic Symptoms

• Otalgia (ear pain) is nearly universal, occurring in 98% of patients 1
• Otorrhea (ear discharge) is common, though classical profuse purulent discharge occurs less frequently in the antibiotic era 2
• Mastoid tenderness on palpation is a key distinguishing feature from uncomplicated acute otitis media 3, 4

Characteristic Physical Findings

• Postauricular swelling and erythema occur in 76% of cases 1
• Protrusion (proptosis) of the auricle is a hallmark sign that increases the likelihood of requiring surgical intervention (relative risk 4.5) 1, 3
• Narrowing of the external auditory canal from posterior-superior wall swelling occurs in 80% of patients 1
• Abnormal tympanic membrane appearance (bulging, erythema) is present in 88% of cases 1, 3

Systemic Symptoms

• Fever is present in 83% of patients and is a cardinal sign 1, 5
• Malaise and irritability are common, particularly in pediatric patients 4
• Elevated temperature ≥39°C indicates severe disease 6

Symptoms Indicating Complications

Warning Signs of Intracranial Extension

When the following symptoms develop, complications such as subperiosteal abscess, labyrinthitis, meningitis, intracranial abscess, subdural empyema, or dural venous sinus thrombosis must be suspected 5, 3:

• Headache 5, 7
• Vertigo or dizziness 5, 8
• Meningismus and neck rigidity 5, 6
• Seizures 5, 4
• Neurological deficits or altered mental status 5, 4
• Cranial nerve deficits, particularly facial nerve palsy (occurs in 40% of intracranial complications) 5, 7, 4

Persistent or Worsening Symptoms

• Persistent otorrhea, otalgia, and headache despite antibiotic treatment suggest developing complications 7
• Prolonged high fever unresponsive to therapy 7
• Failure to improve after 48 hours of appropriate antibiotic treatment warrants imaging 3

Important Clinical Context

Atypical Presentations

• Absence of antecedent acute otitis media occurs in 45% of patients, meaning mastoiditis can develop without a clear preceding ear infection 1
• Classical symptoms like protrusion of the posterior-superior wall of the external auditory canal and profuse purulent discharge occur less frequently in the modern antibiotic era 2
• The duration of mastoiditis development has shortened, and many classical symptoms may be attenuated 2

Age-Related Considerations

• Mastoiditis most commonly affects pediatric patients, though adults can be affected 5, 4
• In children, irritability and fever may be more prominent than localized symptoms 6

Common Pitfalls to Avoid

• Do not rely solely on otoscopic findings—always examine the mastoid area in cases of severe or persistent acute otitis media, as the key distinction is the presence of mastoid tenderness, retroauricular swelling, and auricle protrusion 3
• Mastoiditis can develop despite prior antibiotic treatment for acute otitis media (33-81% of cases had received antibiotics previously) 3
• Normal inflammatory markers should not exclude the diagnosis—clinical examination findings are paramount 4
• The incidence of life-threatening complications like meningitis and meningoencephalitis has increased despite overall decreased mastoiditis incidence, requiring a high index of suspicion 2
• Persistent symptoms warrant imaging—CT temporal bone with IV contrast should be obtained when clinical suspicion exists, especially if symptoms fail to improve after 48 hours of treatment 3