What are the indications for mastoid surgery?

Indications for Mastoid Surgery

Mastoid surgery is indicated primarily for acute mastoiditis with intracranial complications, failure of conservative management after 48-72 hours of IV antibiotics, or presence of subperiosteal abscess >20mm, cholesteatoma, or granulation tissue. 1, 2, 3, 4

Initial Conservative Management

The first-line approach for acute mastoiditis is medical therapy with IV broad-spectrum antibiotics combined with myringotomy with or without tympanostomy tube insertion, reserving mastoidectomy for specific failure scenarios or complications. 1, 2

• Success rates for conservative approaches: Antibiotics alone achieve success in only 10% of cases, while antibiotics plus myringotomy succeed in 68% of cases. 1, 2
• Myringotomy with transtympanic drainage is the most frequently used surgical technique, employed in 86.6% of mastoiditis cases. 3
• Reassessment timing is critical: If no improvement occurs after 48-72 hours of IV antibiotics, or if clinical deterioration occurs at any point, proceed to CT imaging and consider mastoidectomy. 2

Absolute Indications for Mastoidectomy

1. Intracranial Complications

• Brain abscess (most common intracranial complication), meningitis, subdural empyema, or sigmoid sinus thrombosis require immediate mastoidectomy, often combined with neurosurgical intervention. 1, 2, 3
• Intracranial complications occurred in 28.9% of pediatric mastoiditis cases in one series, with 19.2% requiring neurosurgical procedures. 3
• Imaging is mandatory: Obtain CT temporal bone with IV contrast if patient fails to improve; obtain MRI without and with IV contrast if intracranial complications are suspected, as MRI has higher sensitivity for detecting brain abscess and dural venous sinus thrombosis. 2

2. Large Subperiosteal Abscess

• If mean abscess size exceeds 20mm, incision and drainage along with myringotomy and tube placement should be the initial treatment. 3
• For subperiosteal abscess, 57% of children are successfully treated with needle aspiration and myringotomy without mastoidectomy. 1
• However, if abscess is large or fails needle aspiration, proceed to mastoidectomy. 3, 4

3. Failure of Conservative Management

• Persistent drainage despite myringotomy and antibiotics after 48-72 hours. 2, 4
• Clinical deterioration at any point during conservative treatment. 2
• Continued fever, worsening postauricular swelling, or progressive hearing loss despite appropriate medical therapy. 4

4. Presence of Cholesteatoma or Granulation Tissue

• Intraoperative or imaging findings of cholesteatoma or extensive granulation tissue mandate mastoidectomy. 4

5. Chronic Mastoiditis with Persistent Effusion

• In rare cases where conventional treatment (antibiotics, decongestants, ventilation tubes) fails to control chronic middle ear effusion with mastoid involvement, mastoidectomy may be indicated to reestablish aeration of the mastoid air cell system. 5

Relative Indications

Patient Age and Weight Considerations

• Exteriorization of infection in children >30 months or >15 kg weight warrants consideration for mastoidectomy. 4
• Younger or smaller children may be managed more conservatively initially. 4

Recurrent Acute Mastoiditis

• Multiple episodes despite appropriate medical management may indicate need for definitive surgical intervention. 4

Surgical Technique Selection

• Simple mastoidectomy with intact canal wall (ICW) is preferred for most cases with complications, based on extent of lesions and degree of hearing loss. 4
• Canal wall down (CWD) mastoidectomy is reserved for severe complications with extensive disease. 4
• The surgical technique correlates with severity of complication: more severe complications require more aggressive surgical approaches. 3

Critical Pitfalls to Avoid

• Prior antibiotic treatment does not prevent mastoiditis: 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission, so maintain high clinical suspicion even in previously treated patients. 1, 2
• Do not delay imaging in non-resolving cases: No reliable clinical signs distinguish patients with coexistent intracranial complications, making CT or MRI crucial. 2
• Persistent middle ear effusion post-treatment is expected: 60-70% of children have middle ear effusion 2 weeks after treatment, decreasing to 10-25% at 3 months; this does not require mastoidectomy unless symptomatic or associated with other complications. 2

Outcomes and Complications

• Mastoidectomy success rate is 97% for resolving disease. 6
• Surgical complications include: iatrogenic facial nerve palsy (1.7%), sensorineural hearing loss (1.7-2.7%), neurological sequelae (5.4%), and need for reoperation (5.4%). 3, 7
• Intracranial and multiple concomitant complications are associated with longer hospital stays, ICU occupancy, higher risk of neurosurgical intervention, and neurological sequelae. 3
• The comparative risk of developing severe complications from untreated mastoid disease (3.8% over 40 years) is similar to surgical risks, but the number of life-threatening intracranial complications from untreated disease is significant. 7

Special Consideration: Ménière's Disease

• Mastoidectomy alone is NOT recommended as therapeutic treatment for Ménière's disease, as the Danish Sham Surgery Study demonstrated that simple mastoidectomy (used as placebo) resulted in 70% vertigo resolution, making it impossible to distinguish therapeutic effect from placebo effect. 8