What are the signs and symptoms of mastoiditis?

Signs and Symptoms of Mastoiditis

The key clinical distinction between mastoiditis and uncomplicated acute otitis media is the presence of mastoid tenderness, retroauricular swelling, and protrusion of the auricle—these three findings are the hallmark signs that should prompt immediate suspicion for mastoiditis. 1

Cardinal Physical Examination Findings

The classic triad of mastoiditis includes:

• Mastoid tenderness on palpation - present in approximately 57% of pediatric cases 2
• Retroauricular swelling and erythema - visible swelling behind the ear that distinguishes mastoiditis from simple otitis media 1, 3
• Protrusion of the auricle - the ear appears pushed forward and outward from the head 1, 4

However, these classic findings are becoming less common in modern practice, with many cases presenting atypically, particularly in adults where typical presentation occurs in only 48% of cases 4. This makes clinical vigilance essential.

Otoscopic Findings

On ear examination, you will typically find:

• Bulging tympanic membrane - the most reliable sign, similar to acute otitis media 1
• Intense erythema of the tympanic membrane - present in approximately 36% of pediatric cases 1, 2
• Middle ear effusion with limited or absent tympanic membrane mobility 1
• Otorrhea if tympanic membrane rupture has occurred 1, 3
• Blurred tympanic membrane - seen in all cases in one pediatric series 2

Systemic Signs

• Fever - present in 83% of patients and considered a cardinal sign; temperature ≥39°C indicates severe disease 5
• Malaise and general illness 3
• Irritability - particularly prominent in children 5

Critical Red Flag Symptoms Indicating Complications

You must immediately suspect intracranial or other serious complications when any of these symptoms develop 5:

• Headache - suggests meningitis, intracranial abscess, or dural venous sinus thrombosis 1, 5
• Vertigo or dizziness - indicates possible labyrinthitis 1, 5
• Meningismus and neck rigidity - signs of meningeal irritation 1, 5
• Seizures 1, 5
• Neurological deficits or altered mental status 1, 5
• Cranial nerve deficits, particularly facial nerve palsy - occurs in 40% of intracranial complications 5

Complications occur frequently, with meningitis developing in 15-24% of adult cases in some series 4.

Important Clinical Context and Timing

• Mastoiditis can be the first presentation of ear disease in 54-70% of cases, meaning patients may have no prior history of otitis media 2, 6
• Pain and fever persisting beyond 4 days despite appropriate antibiotic treatment for acute otitis media are the most important harbingers of developing mastoiditis 6
• Mastoiditis can develop despite prior antibiotic treatment for acute otitis media, occurring in 33-81% of cases 1, 5

Common Diagnostic Pitfalls to Avoid

• Do not rely solely on otoscopic findings - always examine the mastoid area by palpating for tenderness and inspecting for retroauricular swelling in any case of severe or persistent acute otitis media 1, 5
• Do not be falsely reassured by prior antibiotic treatment - the majority of mastoiditis cases occur despite antibiotics 1, 5
• Do not exclude mastoiditis based on normal inflammatory markers - normal white blood cell count and other markers should not rule out the diagnosis 3
• Recognize that classic symptoms are often absent - particularly in adults and in the modern antibiotic era, atypical presentations are increasingly common 4

When to Obtain Imaging

Obtain CT temporal bone with IV contrast when 1, 5:

• Clinical suspicion exists based on the above findings
• Symptoms fail to improve after 48 hours of antibiotic treatment
• Any red flag symptoms suggesting complications are present
• You are uncertain of the diagnosis clinically