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Acute mastoiditis in children: Clinical features and diagnosis

Acute mastoiditis in children: Clinical features and diagnosis
Literature review current through: Jan 2024.
This topic last updated: May 10, 2023.

INTRODUCTION — Acute mastoiditis is the most common suppurative complication of acute otitis media (AOM) [1]. In many cases, it may be the first evidence of AOM [2].

The clinical features and diagnosis of acute mastoiditis in children will be reviewed here. The treatment, outcome, and prevention of acute mastoiditis, as well as issues related to AOM, are discussed separately.

(See "Acute mastoiditis in children: Treatment and prevention".)

(See "Acute otitis media in children: Epidemiology, microbiology, and complications".)

(See "Acute otitis media in children: Clinical manifestations and diagnosis".)

(See "Acute otitis media in children: Treatment".)

(See "Acute otitis media in children: Prevention of recurrence".)

DEFINITIONS

Mastoiditis is a suppurative infection of the mastoid air cells (figure 1).

Acute mastoiditis is a suppurative infection of the mastoid air cells with symptoms of less than one month's duration.

Acute mastoiditis is subdivided according to the pathologic stage [1]:

Acute mastoiditis with periostitis (also called incipient mastoiditis) is defined by the presence of purulent material in the mastoid cavities without destruction of the bony septa. The finding of fluid in the mastoid air cells on imaging is nonspecific and is commonly seen in children with acute otitis media (AOM) or otitis media with effusion. Thus, this finding alone is not diagnostic of mastoiditis. The diagnosis is based on clinical findings, including postauricular tenderness, erythema, and swelling with protrusion of the auricle (picture 1). (See 'Diagnosis' below.)

Coalescent mastoiditis (also called "acute mastoid osteitis") is defined by destruction of the thin bony septae between air cells (image 1). This imaging finding is diagnostic of mastoiditis; however, most children do not require imaging to make the diagnosis (see 'Indications for imaging' below). Coalescent mastoiditis may be followed by the formation of abscess cavities and the dissection of pus into adjacent areas, the most common of which is a subperiosteal abscess.

Subacute mastoiditis (also called masked mastoiditis) refers to low-grade but persistent infection in the middle ear and mastoid with destruction of the bony septae between air cells [3]. It occurs in patients with persistent otitis media with effusion or recurrent episodes of AOM without sufficient antimicrobial therapy.

Chronic mastoiditis is a suppurative infection of the mastoid air cells of longstanding duration (months to years) [4].

ANATOMY — The mastoid is a division of the temporal bone, which forms portions of the side and base of the skull [5]. At birth, the mastoid consists of a single cell, the antrum, which is connected to the middle ear by a narrow channel, the aditus ad antrum (figure 1) [1]. As the child grows, the mastoid bone becomes pneumatized, resulting in a series of interconnected air cells, lined by modified respiratory epithelium.

The relationship between the mastoid, eustachian tube, and middle ear is a central feature of the pathogenesis of mastoiditis. The proximity of the mastoid to the facial nerve, semicircular canals, sternocleidomastoid muscle, jugular vein, internal carotid artery, sigmoid sinus, brain, and meninges is crucial to the development of complications (figure 2).

PATHOGENESIS — Acute mastoiditis is a complication of acute otitis media (AOM). The middle ear cavity and mastoid air spaces are continuous [4]. During an episode of AOM, the mucosa lining the middle ear, and often that lining the mastoid, becomes inflamed [1]. In almost all cases, the inflammation resolves as the AOM improves. When inflammation persists, purulent material accumulates within the mastoid cavities (acute mastoiditis with periostitis) [1,5,6]. As the pressure increases, the thin bony septae between air cells may be destroyed (coalescent mastoiditis) [1,5,6]. (See 'Definitions' above.)

Coalescent mastoiditis may be followed by the formation of abscess cavities and, ultimately, by the dissection of pus into adjacent areas. The direction of dissection determines the clinical presentation and complications (figure 2) [1,6-8]:

Through the aditus ad antrum (figure 1) – Resolution (if the eustachian tube is patent) or tympanic membrane perforation with otorrhea (if the eustachian tube is obstructed).

Through the lateral cortex of the mastoid – Subperiosteal abscess (typically posterior to the pinna).

Inferiorly, through the mastoid tip – Bezold abscess (an abscess in the neck beneath the attachment of the sternocleidomastoid and digastric muscles).

Medially to the petrous air cells – Petrositis; petrositis may be associated with facial nerve paralysis or Gradenigo syndrome (otitis media, eye pain, ipsilateral abducens [sixth cranial nerve] palsy, and possibly other cranial nerve deficits).

Posteriorly to the occipital bone – Osteomyelitis of the calvaria (Citelli abscess).

Through the oval or round window into the bony labyrinth – Suppurative labyrinthitis. (See "Vestibular neuritis and labyrinthitis", section on 'Clinical manifestations'.)

Toward the inner cortical bone – Suppurative central nervous system complications (eg, meningitis; venous sinus thrombosis; epidural, subdural, temporal lobe, or cerebellar abscess). (See 'Complications' below.)

MICROBIOLOGY — The two bacterial species most often isolated from children with acute mastoiditis are Streptococcus pneumoniae and Streptococcus pyogenes. Less commonly, Fusobacterium necrophorum, Haemophilus influenzae (nontypeable), and Staphylococcus aureus (including methicillin-resistant S. aureus) are recovered [9-30].

The frequency of pneumococcal isolates with high-level penicillin resistance in children with mastoiditis has decreased in the pneumococcal conjugate vaccine (PCV) era, largely related to decreases in serotype 19A isolates [31]. However, it takes approximately four years to reach peak immunity after PCV administration and nonvaccine strains emerge, some of which may be resistant to penicillin [32]. (See "Pneumococcal vaccination in children".)

Pseudomonas aeruginosa has been isolated frequently in some series [10,23]; however, its frequency as a true pathogen is likely overestimated since it may be recovered if the sample for culture is taken from the external canal in patients with otorrhea [10]. P. aeruginosa should only be considered as a potential pathogen in children with acute mastoiditis who have a history of recurrent acute otitis media (AOM) and recent antibiotic use, especially if there is a perforation of the tympanic membrane or if the process is potentially nonacute [33]. Features that may suggest infection caused by F. necrophorum include poor response to oral antibiotics and markedly elevated inflammatory markers [34].

Precise delineation of the microbiology of acute mastoiditis is difficult. Most of the case series describing the microbiology are retrospective, and specimens for microbiology were not obtained from all patients [9-24]. In addition, antibiotic therapy, which may affect the yield of cultures, frequently is administered for AOM before symptoms or signs of mastoiditis are present [10,19,20,23].

EPIDEMIOLOGY — The epidemiology of acute mastoiditis parallels that of acute otitis media (AOM), with the highest incidence in children younger than two years [26,35,36]. A history of recurrent AOM is a risk factor for acute mastoiditis, although for at least 50 percent of affected children, it occurs with their first episode of AOM [10].

Factors that may influence the likelihood of a child developing acute mastoiditis include the frequency of AOM, causative pathogen(s), and initial management (upfront antibiotic treatment versus observation). The frequency and microbiology of AOM has been dramatically altered by the near-universal adoption of pneumococcal conjugate vaccines. Given the decline in cases of AOM in the post-PCV era, it is probable that acute mastoiditis is declining as well. (See 'Pathogenesis' above and "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Epidemiology'.)

Reports describing the incidence of acute mastoiditis during and after the 1990s are conflicting as to whether the incidence is increasing [11,12,27,35,37-42]. Few of these reports are population based; accordingly, it is uncertain whether changes in the incidence in cases of mastoiditis reflect actual increases, a change in referral patterns, or other epiphenomena (eg, antibiotic prescribing patterns, effects of the PCV, etc). Differences in management strategies for management of AOM (eg, upfront antibiotic treatment versus "watchful waiting,") may also influence rates of complications.

CLINICAL FEATURES — The clinical spectrum of mastoiditis ranges from a lack of symptoms with spontaneous resolution to progressive disease with life-threatening complications [1,4]. The presentation is determined by age, stage of infection, and path of drainage of purulent material [1,7,26]. (See 'Pathogenesis' above.)

Acute mastoiditis — Characteristic features of acute coalescent mastoiditis include [1,43,44]:

Postauricular tenderness, erythema, swelling (with loss of the postauricular crease), fluctuance (or draining fistula), or mass (picture 2)

Protrusion of the auricle (picture 1)

Ear pain, which is a nonspecific finding and may manifest as irritability in young children

In a systematic review of the diagnostic criteria for acute mastoiditis (65 studies published between 1980 and 2007), the relative frequencies of clinical findings were as follows:

Lethargy/malaise (96 percent)

Abnormal tympanic membrane (82 percent)

Postauricular erythema, postauricular tenderness, and/or protrusion of the pinna (80 percent)

Fever (76 percent)

Narrowing of the external auditory canal (71 percent)

Ear pain (67 percent)

Otorrhea (50 percent)

Approximately 40 percent of children had a history of previous otitis media, and 50 percent had received antibiotics before admission [44].

Examination of the tympanic membrane usually reveals abnormal findings (eg, bulging, middle ear effusion, perforation) (picture 3); however, often, the tympanic membrane cannot be seen due to swelling of the external auditory canal. On average, 80 percent of children in the systematic review had acute otitis media (AOM) at the time of presentation [44]. However, the absence of AOM (current or recent) does not exclude a diagnosis of acute mastoiditis. Middle ear effusion may be absent if there is obstruction of the aditus ad antrum with a patent eustachian tube (figure 1) [1]. (See 'Pathogenesis' above.)

Fever is a nonspecific symptom but is sensitive and may be predictive of complications or the need for surgical intervention [5,14,44,45]. High-spiking "picket-fence" fevers may be indicative of sigmoid sinus thrombophlebitis [46]. Other systemic symptoms and signs may include lethargy, malaise, irritability, poor feeding, or diarrhea [44].

Subacute (masked) mastoiditis — Clinical features of subacute (masked) mastoiditis include fever, cough, ear pain, and tympanic membrane findings compatible with AOM (picture 3). Subacute mastoiditis occasionally presents with an extracranial or intracranial complication without signs of AOM or mastoiditis [3].

Subacute mastoiditis should be considered in children with AOM that is not responding to antibiotics and in children with signs of intracranial infection without another focus of infection. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)

Complications — Complications of mastoiditis are related to the spread of infection or inflammation from the middle ear or mastoid to contiguous structures (figure 2). In some cases, the complication (eg, cranial nerve palsy) is the presenting complaint.

In most case series, the rate of complications is approximately 15 to 30 percent (range 7 to 60 percent) [2,9,10,14,15,25,26,36,44,47]. Intracranial complications account for a considerable proportion of these. In a systematic review of 42 studies including >2000 children with acute mastoiditis, intracranial complications occurred on average in 17 percent [44]. In a multicenter study, S. pyogenes was associated with the highest rate of complications at presentation (50 percent) and S. aureus with the highest rate of complications during hospitalization (31 percent) [10].

Extracranial complications – Extracranial complications include (figure 2):

Subperiosteal abscess – Signs of subperiosteal abscess include erythema, fluctuance, and a tender mass overlying the mastoid bone (picture 2). In a systematic review of 35 studies, subperiosteal abscess occurred in an average of 58 percent of cases of acute mastoiditis [44].

Facial nerve paralysis – Facial nerve paralysis can result from infection or inflammatory compression of the facial nerve as it traverses the narrow canal in the petrous portion of the temporal bone. (See "Facial nerve palsy in children".)

Hearing loss – Acute mastoiditis may result in transient hearing loss due to obstruction of the external auditory canal and/or middle ear effusion or may result in permanent hearing loss due to damage to the ossicles of the middle ear or suppurative labyrinthitis causing damage to the cochlea [4].

Labyrinthitis – Inflammation or infection of the bony labyrinth may cause labyrinthitis [4]. Clinical features of labyrinthitis include tinnitus, hearing loss, nausea, vomiting, dizziness, vertigo, and nystagmus. (See "Vestibular neuritis and labyrinthitis", section on 'Clinical manifestations'.)

Osteomyelitis – Infection in the mastoid may spread to other parts of the skull, resulting in osteomyelitis. Osteomyelitis of the petrous bone (petrositis) may be associated with facial nerve paralysis or Gradenigo syndrome (ie, otorrhea, retroorbital pain, ipsilateral abducens [sixth cranial nerve] palsy, and possibly other cranial nerve deficits). Osteomyelitis of the calvaria is known as Citelli abscess [6,7].

Bezold abscess – A Bezold abscess is a neck abscess located beneath the sternocleidomastoid and digastric muscles [6,7]. Clinical features of Bezold abscess include swelling and tenderness below the mastoid process and under the sternocleidomastoid muscle [4].

Intracranial complications – Intracranial complications, which are discussed separately, include:

Meningitis (see "Bacterial meningitis in children older than one month: Clinical features and diagnosis")

Temporal lobe or cerebellar abscess (see "Pathogenesis, clinical manifestations, and diagnosis of brain abscess")

Epidural or subdural abscess (see "Intracranial epidural abscess")

Venous sinus thrombosis (see "Septic dural sinus thrombosis")

LABORATORY FEATURES — The peripheral white blood cell count in children with acute mastoiditis may be normal or elevated, often with a left shift [4,11]. The erythrocyte sedimentation rate or C-reactive protein also may be elevated [14,15]. These laboratory findings are nonspecific. They are generally not helpful in making the diagnosis. (See 'Diagnosis' below.)

RADIOGRAPHIC FEATURES

Indications for imaging — Imaging of the temporal bone is not necessary to make the diagnosis of acute mastoiditis in children with characteristic clinical findings [48,49]. However, it may be necessary to confirm the diagnosis in children without characteristic findings (eg, persistent ear pain or drainage without postauricular findings); determine the stage (acute mastoiditis with periostitis versus coalescent mastoiditis), which affects management; or evaluate suspected complications.

Indications for imaging in children with mastoiditis or suspected mastoiditis may include [2,4,5,15,50,51]:

Clinical findings suggestive of extracranial complications (eg, postauricular mass, neck mass, cranial nerve deficits, retroorbital pain, hearing loss, tinnitus, vertigo, nystagmus) (see 'Complications' above)

Clinical findings suggestive of intracranial complications (eg, meningeal signs, cranial nerve deficits, focal neurologic findings, altered level of consciousness) (see 'Complications' above)

Severe illness or toxic appearance

Acute otitis media (AOM) that is not responding to antibiotics (a possible indication of subacute [masked] mastoiditis) (see 'Subacute (masked) mastoiditis' above)

Imaging modality — When imaging is indicated, changes in the temporal bone are best visualized with contrast-enhanced computed tomography (CT).

If an intracranial complication is suspected, cranial CT with intravenous contrast or cranial magnetic resonance imaging (MRI) with gadolinium should be performed [8]. These studies may confirm the diagnosis and delineate the extent of suspected disease. MRI with gadolinium has greater sensitivity than CT for detection of extra-axial fluid collections and associated vascular problems [50,52]. (See 'Subacute (masked) mastoiditis' above and 'Complications' above.)

Findings — CT findings in children with acute mastoiditis include [1,4,5,25,53]:

Mastoid opacification or clouding – Fluid and/or mucosal thickening in the middle ear and mastoid is a nonspecific finding that occurs early in the course. Mastoid opacification is a common incidental finding in children and is seen on approximately 15 to 20 percent of CTs and MRIs obtained for other reasons [54,55]. It is a particularly common finding in children with AOM. Thus, an isolated finding of mastoid opacification is not diagnostic of mastoiditis. However, if this finding is absent, the diagnosis of mastoiditis can be excluded [25].

Coalescent mastoiditis – Coalescent mastoiditis refers to loss of definition of the bony septae that define the mastoid air cells (image 1). This finding is diagnostic of mastoiditis.

Destruction or irregularity of the mastoid cortex (image 2).

Periosteal thickening, disruption of the periosteum, subperiosteal abscess.

DIAGNOSIS

Clinical diagnosis — The diagnosis of acute mastoiditis is usually made clinically in children with characteristic findings. The criteria that are used most frequently to make the diagnosis include [4,44,56]:

Postauricular erythema, tenderness, swelling, fluctuance, or mass (picture 2)

Protrusion of the auricle (picture 1)

Otalgia

Fever

Tympanic membrane findings consistent with acute otitis media (AOM; eg, bulging, marked erythema (picture 3) or acute perforation with purulent otorrhea in the absence of otitis externa) often are present. A normal-appearing tympanic membrane usually (but not invariably) excludes mastoiditis (see 'Differential diagnosis' below). In a systematic review of diagnostic features of acute mastoiditis, the characteristic postauricular findings, displacement of the auricle, and AOM were present in 79 to 85 percent of children [44]. (See 'Acute mastoiditis' above.)

Imaging — Imaging is not necessary to make the diagnosis of acute mastoiditis in children with characteristic clinical findings [48]. However, it may be necessary to confirm the diagnosis in children without characteristic findings (eg, persistent ear pain or drainage without postauricular findings); determine the stage (acute mastoiditis with periostitis versus coalescent mastoiditis), which affects management; or evaluate suspected complications. Indications for imaging, choice of imaging modality, and characteristic findings are discussed above. (See 'Indications for imaging' above.)

FURTHER EVALUATION

Microbiologic studies — The importance of obtaining clinical specimens for microbiology cannot be overemphasized. Results from cultures and susceptibility testing are crucial in guiding therapy, given the variety of microorganisms that can cause acute mastoiditis (eg, S. pneumoniae, S. pyogenes, F. necrophorum, and, much less commonly, H. influenzae (nontypeable) and S. aureus) and the potential for antibiotic resistance among isolates of S. pneumoniae and S. aureus [1,6]. (See 'Microbiology' above and "Acute mastoiditis in children: Treatment and prevention", section on 'Antimicrobial therapy'.)

We suggest the following microbiologic studies be obtained from children with mastoiditis:

Blood cultures – Aerobic and anaerobic blood cultures should be obtained if the patient's temperature is ≥39°C (102.2°F). However, bacteremia is uncommon in patients with mastoiditis.

Middle ear specimens – Middle ear drainage (eg, tympanocentesis, myringotomy) is indicated in the treatment of acute mastoiditis and should be performed even if there is a subperiosteal abscess (to increase the possibility of recovering an organism). Tympanocentesis can be performed by anyone who is skilled in the procedure. Additional details are provided separately. (See "Acute mastoiditis in children: Treatment and prevention", section on 'Drainage'.)

Middle ear specimens should be sent for Gram stain, aerobic and anaerobic culture, and antimicrobial susceptibility testing. Clinical specimens for microbiology should be obtained from the middle ear by tympanocentesis through an intact eardrum or by aspiration through a tympanostomy tube or perforation. Cultures should not be obtained from the external canal because they may be contaminated with P. aeruginosa or S. aureus.

Subperiosteal abscess fluid (if applicable) – If a subperiosteal abscess is present, samples of subperiosteal abscess fluid should be sent for Gram stain, aerobic and anaerobic culture, and antimicrobial susceptibility testing. Subperiosteal abscess should be percutaneously aspirated, particularly if definitive surgery will be delayed. (See "Acute mastoiditis in children: Treatment and prevention", section on 'Drainage'.)

Cerebrospinal fluid (if there are signs of meningitis) – Cerebrospinal fluid specimens for culture and susceptibility testing should be obtained in children with symptoms or signs of meningeal irritation (eg, stiff neck, headache). Computed tomography (CT) should be obtained before lumbar puncture in children with papilledema or findings consistent with intracranial extension (eg, cranial nerve palsy) [4]. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation'.)

Immunologic evaluation — Immunologic evaluation may be warranted in children with recurrent episodes of acute otitis media (AOM) leading to mastoiditis [4,57]. (See "Approach to the child with recurrent infections", section on 'Infection history'.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of acute mastoiditis includes other causes of postauricular inflammation or swelling (table 1) [1,4,8]:

Lymphadenopathy – Postauricular lymphadenopathy (eg, from a scalp infection) may cause postauricular swelling. In contrast with the poorly circumscribed and immobile postauricular mass in acute mastoiditis (picture 2), lymphadenopathy usually is well circumscribed and freely mobile (picture 4). Additional features that may distinguish posterior lymphadenopathy from mastoiditis include lack of displacement of the auricle, preservation of the postauricular crease, and normal-appearing tympanic membrane.

Periauricular inflammation or cellulitis – Periauricular cellulitis (picture 5) may be distinguished from mastoiditis by the normal appearance of the tympanic membrane and the absence of otitis externa. Most commonly, this will occur secondary to an insect or spider bite or minor trauma to the skin.

Periauricular cellulitis related to otitis externa – This is a common mimicker of mastoiditis [58]. It may occur with or without acute otitis media (AOM) that has resulted in perforation of the tympanic membrane. Severe pain over the tragus and pinna differentiates this entity from mastoiditis.

Perichondritis of the auricle – Perichondritis of the auricle is characterized by swelling and erythema of the pinna (picture 6) and may spread to the periosteum of the postauricular area. In contrast with acute mastoiditis, the postauricular crease is preserved and the tympanic membrane appears normal.

Mumps – Mumps causes swelling of the parotid gland anterior and inferior to the auricle. (See "Mumps".)

Tumor – Benign and malignant tumors of the mastoid bone (eg, aneurysmal bone cyst, acute lymphocytic leukemia, Langerhans cell histiocytosis) may have clinical features similar to those of mastoiditis [59]. The tympanic membrane examination usually is normal in children with such tumors. (See "Nonmalignant bone lesions in children and adolescents", section on 'Aneurysmal bone cyst' and "Overview of the clinical presentation and diagnosis of acute lymphoblastic leukemia/lymphoma in children", section on 'Presentation' and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis", section on 'Clinical manifestations'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute otitis media, otitis media with effusion, and external otitis".)

SUMMARY AND RECOMMENDATIONS

Pathogenesis – Acute mastoiditis is a complication of acute otitis media (AOM) in which purulent material accumulates within the mastoid cavities. As the pressure increases, the bony septae between the mastoid air cells may be destroyed (coalescent mastoiditis), abscess cavities may form, and the purulent material may dissect into adjacent areas. (See 'Pathogenesis' above.)

Microbiology – The bacterial species most often implicated as the cause of acute mastoiditis are Streptococcus pneumoniae and Streptococcus pyogenes. Less common pathogens include Fusobacterium necrophorum, Haemophilus influenzae (nontypeable), and Staphylococcus aureus. (See 'Microbiology' above.)

Clinical features – The clinical spectrum of mastoiditis ranges from a lack of symptoms with spontaneous resolution to progressive disease with life-threatening complications.

Acute mastoiditis – Characteristic features of coalescent mastoiditis include postauricular abnormalities (tenderness, erythema, swelling, fluctuance, mass (picture 2)) and protrusion of the auricle (picture 1); most patients also have fever and ear pain. (See 'Acute mastoiditis' above.)

Subacute mastoiditis – Subacute (masked) mastoiditis should be considered in children with AOM that is not responding to antibiotics and in children with signs of intracranial disease without another focus of infection. (See 'Subacute (masked) mastoiditis' above.)

Complications – Complications of mastoiditis are related to the spread of infection or inflammation from the middle ear or mastoid to contiguous structures (figure 2). They include subperiosteal abscess, facial nerve paralysis, hearing loss, labyrinthitis, osteomyelitis, neck abscess, meningitis, temporal lobe or cerebellar abscess, epidural empyema, subdural empyema, and venous sinus thrombosis. (See 'Complications' above.)

Diagnosis – The diagnosis of acute coalescent mastoiditis is usually made clinically in children with characteristic examination findings (fever; ear pain; postauricular erythema, tenderness, and swelling; displacement of the auricle (picture 1)). Imaging may be necessary to confirm the diagnosis, determine the stage and extent of infection, or evaluate suspected complications. (See 'Clinical diagnosis' above and 'Radiographic features' above.)

Microbiologic testing – Results from cultures and susceptibility testing are crucial in guiding therapy. Specimens from the middle ear and/or abscesses that are obtained through aspiration or surgical drainage should be submitted for Gram stain, aerobic and anaerobic cultures, and antimicrobial susceptibility testing. Cerebrospinal fluid specimens for culture and susceptibility testing should be obtained in children with symptoms or signs of meningeal irritation. Blood cultures are rarely positive but can help in determining the etiology. (See 'Microbiologic studies' above and "Acute mastoiditis in children: Treatment and prevention", section on 'Antimicrobial therapy' and "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Diagnosis'.)

Differential diagnosis – The differential diagnosis of acute mastoiditis includes other causes of postauricular inflammation or swelling (table 1): postauricular lymphadenopathy (picture 4), periauricular cellulitis without otitis externa (picture 5), periauricular cellulitis with otitis externa, perichondritis of the auricle (picture 6), mumps, and benign and malignant tumors of the mastoid bone. (See 'Differential diagnosis' above.)

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Topic 6062 Version 29.0

References

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