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THE CASE:

For the past 3 days, a 45-year-old man has had discomfort andloss of hearing in one ear. There is no fever or history of trauma. The manwas recently treated for an ear infection at a local clinic. Physical examinationreveals erythema of the postauricular area and purulent exudate from the earcanal.What do you suspect is the cause of the patient's complaints?

• Acute mastoiditis
• Mastoid trauma
• Otitis externa
• Parotitis

DISCUSSION:

This patient has

acute mastoiditis,

acondition that was once the most common complication ofacute otitis media but is rarely seen today. Mastoiditis isdescribed as classic when it presents as an acute processfollowing acute otitis media. Latent mastoiditis, which isusually a chronic process, often follows a partially treatedacute otitis media.Infection of the middle ear spreads to involve themastoid air cells. This causes secondary inflammation, infection,and destruction of the mastoid bone. Furtherspread may involve the canal of the facial nerve, the posteriorcranial fossa, the lateral and sigmoid sinuses, and thetemporal bone, and may lead to life-threatening disease.Mastoiditis affects males and females equally; it is mostcommonly seen in infants aged 6 to 13 months, which parallelsthe incidence of otitis media.Patients with classic mastoiditis often complain offever and discomfort in or behind the ear; they may havea recent history of acute otitis media. There may be protrusionof the auricle; tenderness, erythema, or swellingof the mastoid area; and a bulging tympanic membrane.Patients with latent mastoiditis may report fever, recurrentdiscomfort in the ear region, and chronic or recurrentotitis media, but they frequently have no mastoiddiscomfort. The tympanic membrane is likely to appearnormal. Infants may demonstrate nonspecific symptoms,such as irritability, poor feeding, or diarrhea.The bacteria that cause mastoiditis are the same organismsthat cause acute otitis media:

Streptococcus pneumoniae,Haemophilus influenzae, Moraxella catarrhalis, Staphylococcusspecies,

and

Streptococcus pyogenes

. Gram-negative organismsare more prevalent in infants, patients with chronicmastoiditis, and those with more virulent infections.Laboratory studies may show leukocytosis and anelevated erythrocyte sedimentation rate. Culture andGram staining of middle-ear fluids are recommended beforeantibiotic therapy is initiated. The diagnosis of mastoiditisis a clinical one. Although plain radiographs maybe helpful, CT is the modality of choice to confirm thediagnosis, especially in a patient in whom one suspectsintracranial involvement.Treatment consists of intravenous antibiotics (ceftriaxoneor another third-generation antibiotic, or an aminoglycosideand a penicillinase-resistant penicillin) and consultationwith an otolaryngologist for myringotomy ortympanostomy tube placement. Secondary complications-such as mastoid osteitis, intracranial involvement,or subperiosteal abscess-or failure to respond to antibiotictherapy are indications for mastoidectomy.

Mastoid trauma

may result in postauricular erythemaand ecchymosis (Battle sign) or cerebrospinal fluid otorrheaconsistent with a basilar skull fracture.

Otitis externa

is most frequently caused by bacteria(

Staphylococcus aureus

or other, gram-negative organisms)or, less commonly, by a fungal pathogen. Moisturetrapped in the ear canal provides a fertile environment forbacteria to proliferate (as in swimmer's ear). Trauma tothe canal allows secondary bacterial invasion. Patientsoften complain of localized discomfort, hearing loss or fullnessin the ear, and a purulent discharge. Secondary cellulitisof the neck may be present. Treatment consists ofantibiotic therapy. Referral to an otolaryngologist is warrantedin complicated cases.

Parotitis

may be the result of bacterial infection (includingtuberculosis); viral infection (including HIV);or an autoimmune disorder (such as Sjgren syndrome).Patients' complaints and physical findings-which varywith the pathology-may include painful or nonpainfulswelling of the parotid gland and dry mouth and eyes.The workup and treatment are based on the history andphysical findings.

References:

FOR MORE INFORMATION:

• Effron D. Photo finish: acute bacterial parotitis. Consultant. 2003;43:789-790.
• Nadol JB Jr, Eavey RD. Acute and chronic mastoiditis: clinical presentation,diagnosis, and management. Curr Clin Top Infect Dis. 1995;15:204-229.