Clinical Review Lesson of the week

Life threatening complications after partially treated mastoiditis

BMJ 2003; 327 doi: http://dx.doi.org/10.1136/bmj.327.7405.41 (Published 03 July 2003) Cite this as: BMJ 2003;327:41
  1. Jemy Jose (jemyjose{at}yahoo.co.uk), specialist registrar1,
  2. Andrew P Coatesworth, consultant2,
  3. Richard Anthony, specialist registrar1,
  4. P Gerard Reilly, consultant2
  1. 1Department of Otolaryngology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX
  2. 2Department of Otolaryngology, York Hospital, Wigginton Road, York YO31 8HE
  1. Correspondence to: Mr J Jose, 109 Ainsty Road, Wetherby LS22 7FY
  • Accepted 25 February 2003

Introduction

The introduction of antibiotics reduced the incidence of mastoiditis after acute otitis media from 50% to 0.4%.1 2 However, mastoiditis still occurs, and partially treated mastoiditis can alter the clinical picture of resultant intracranial and extracranial complications by masking the classic symptoms. We present three such cases, the first two with lateral sinus thrombosis and the third with a Bezold's abscess. We emphasise the importance of heightened awareness of the changing presentation of complications of mastoiditis so that these life threatening conditions can be recognised and treated early.

Case reports

Case 1

A 12 year old boy presented with a three day history of left sided otalgia, with two days of left temporal and parietal headache, vomiting, and true vertigo. He had had no previous otological problems. He had been prescribed co-amoxiclav with a diagnosis of “ear infection.” On examination, he had low grade fever of 37.8°C. He had minor neck stiffness but no focal neurological signs and no papillo-oedema. The left tympanic membrane was red and bulging. There was no tenderness over the mastoid.

On admission the diagnosis was acute otitis media in the left ear with possible intracranial complication. He had a neutrophilia. He was started on intravenous cefotaxime and metronidazole, and contrast enhanced computed tomography was done. This did not show any evidence of intracranial complications, but there was opacification of the left middle ear and mastoid air cells. A myringotomy allowed pus to be discharged under pressure from the middle ear. Culture of the pus grew β haemolytic streptococcus.

Over the subsequent days the clinical picture improved except for a persistent left temporoparietal headache. A magnetic resonance scan was therefore done, which showed an opaque middle ear cleft and lateral sinus thrombosis on the left side (figure). He had an extended cortical mastoidectomy, during which frank pus was released from the lateral sinus. His postoperative recovery was unremarkable. He had a further three weeks of antibiotic treatment and made a full recovery.


Embedded Image

Magnetic resonance scan showing opacification of left middle ear and mastoid air cells (A), lateral sinus thrombosis (B), and adjacent area of meningeal inflammation (C)

Case 2

A 13 month old boy presented with a four day history of fever and right otorrhoea after an acute upper respiratory tract infection. Examination showed an inflamed right eardrum and a postaural inflammatory swelling. This was diagnosed as acute mastoiditis with a subperiosteal abscess. Computed tomography showed a subperiosteal abscess but did not indicate any intracranial complication.

He was started on ceftazidime and metronidazole intravenously followed by incision and drainage of the abscess and cortical mastoidectomy. Postoperatively, he seemed to make satisfactory progress until the second day, when his conscious level deteriorated suddenly and his temperature spiked at 37.6°C. Further computed tomograms did not show any intracranial abnormalities. His conscious level improved over the next 24 hours, but he continued to have low grade spiking fever on subsequent days. In view of this persistent sign, magnetic resonance imaging was done. This showed a right lateral sinus thrombosis with a small right extradural empyema. As he was clinically well and improving, a conservative line was pursued—with antibiotic therapy and close clinical monitoring for a further five weeks. Repeat magnetic resonance imaging showed a resolution of the empyema, and the child remains well.

Case 3

A 19 year old man presented with a two week history of left sided otalgia and hearing loss and a four day history of a tender red swelling at the back of his neck. He had been treated with amoxicillin for an ear infection and the otalgia had improved. The swelling had increased in size, however. He had had no previous otological problems.

On examination, he was feverish, with a temperature of 38.4°C. There was a fluctuant 10 cm diameter erythematous swelling at the apex of his posterior triangle on the left side. The tympanic membrane appeared normal. He had a neutrophilia. He was admitted and started on intravenous co-amoxiclav and metronidazole. Computed tomography was done urgently, followed by magnetic resonance imaging. These showed fluid filling some of the mastoid air cells and a large abscess at the apex of the posterior triangle around the posterior belly of digastric muscle. The abscess was drained and culture of the pus grew Staphylococcus aureus. The antibiotics were changed to flucloxacillin and fusidic acid for a further two weeks, and he made an unremarkable recovery in the following weeks.

Discussion

In Britain only six cases of lateral sinus thrombosis and one case of Bezold's abscess have been reported in the literature in the past 10 years.37 These rare but potentially life threatening conditions still occur, however.

Moreover, unlike in the pre-antibiotic era, the features of these conditions have altered substantially, and these days the presenting signs are subtle. The classic picture of lateral sinus thrombosis used to be a severe wasting illness with fever.8 The fever would be high and swinging, following a so called “picket fence” pattern. As the clot propagated, it would be accompanied by perivenous inflammation, with tenderness along its course and jugular lymphadenopathy. Raised intracranial pressure would cause papillo-oedema and visual loss. Embolic propagation of infected clot would produce infiltrates in the lung fields and septic spread to large joints and subcutaneous tissues.

The patients in this report, however, had been treated with antibiotics for an ear infection in the weeks preceding hospital admission. The two with lateral sinus thrombosis had surgery to drain the abscess, after which the general condition improved. Persistent headache in the first patient and grumbling low grade fever in the second were the only features that directed our suspicion to an intracranial complication. Even though computed tomography was normal, we also did magnetic resonance imaging, which proved the diagnosis and has been shown to be more sensitive in diagnosing intracranial complications of acute otitis media.9

Bezold's abscess, as described by Friedrich Bezold towards the end of the 19th century,10 occurs as a result of pus escaping through the medial side of the mastoid process at the digastric groove. In his classic description, the pus spread along the posterior belly of the digastric muscle to the chin, and, if the condition was left untreated, further extension occurred along the sternomastoid, trapezius, and splenius muscles. Our patient had an acute ear infection before his presentation, which had been treated with antibiotics. Otological symptoms had improved, and it was the swelling in the neck that prompted the referral. Computed tomography proved the diagnosis, and he made a satisfactory recovery after surgery.

These cases show the surprising and tortuous course of complications of ear infections. The characteristic picket fence pattern of fever with lateral sinus thrombosis and the longstanding history of otological problems with Bezold's abscess are often absent. Clinicians have to adopt a high index of suspicion in any patient with ear infection that fails to resolve predictably and consider imaging for early diagnosis of potentially life threatening situations. Magnetic resonance imaging is better than computed tomography for intracranial complications of otitis media.

Complications of mastoiditis can present subtly—use magnetic resonance imaging for identifying intracranial complications

Footnotes

  • Contributors JJ was the principal investigator, analysed the data, and drafted the paper. APC conceived and designed the paper and collected and interpreted the data. RA collected the data and drafted the paper. PGR conceived the paper. All authors helped to revise the paper, and all approved the final draft. JJ will act as guarantor for the paper.

  • Funding No special funding.

  • Competing interests None declared.

References

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