List of Abbreviations
VA – vestibular analyzer
CT – computed tomography
EAC — external auditory canal
AOM – acute otitis media
ESR – erythrocyte sedimentation rate
CRP – C-reactive protein
AUR – auricle
CSOM – chronic suppurative otitis media
CM – chronic mastoiditis
MRSA – (methicillin-resistant Staphylococcus aureus) methicillin-resistant Staphylococcus aureus
Terms and Definitions
Mastoiditis is an acute or chronic destructive inflammation of the mucous membrane, periosteum, and bone framework of the cellular structure of the mastoid process.
Otoantritis is inflammation of the mucous membrane and bone tissue of the mastoid antrum, developing as a complication of acute otitis media in newborns and infants.
Petrositis is a purulent-inflammatory process in the pyramid of the temporal bone.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Mastoiditis is a destructive inflammation of the mucous membrane, periosteum, and bone framework of the cellular structure of the mastoid process.
Primary mastoiditis is an inflammatory-destructive process in the mastoid process developing without preceding otitis media.
Secondary mastoiditis is an inflammatory-destructive process in the mastoid process developing as a complication of otitis media.
Antritis (syn. otoantritis) is a destructive inflammation of the mucous membrane, periosteum, and bone tissue of the mastoid antrum, developing as a complication of acute otitis media in newborns and infants.
Acute mastoiditis refers to inflammatory-destructive changes in the cellular structure of the mastoid process lasting no more than 1 month.
Chronic (latent) mastoiditis refers to inflammatory-destructive changes in the cellular structure of the mastoid process persisting for more than 1 month, most commonly associated with chronic suppurative otitis media (CSOM) or protracted acute otitis media (AOM).
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The etiology of primary mastoiditis is traumatic (blows, contusions, fractures and fissures of the skull bones, gunshot wounds) and hematogenous (in septicopyemia, spread of purulent process from lymph nodes of the mastoid region). Isolated involvement of the mastoid process in specific infections (tuberculosis, infectious granulomas) is possible [1, 2].
In secondary mastoiditis, the penetration of infection into the cellular structure of the mastoid process occurs predominantly via the otogenic route in acute or chronic suppurative otitis media [1].
Mastoiditis is caused, as a rule, by the same pathogens as acute suppurative otitis media. Streptococcus pneumoniae and Streptococcus pyogenes predominate. Haemophilus influenzae, Pseudomonas aeruginosa, Fusobacterium necrophorum, S. aureus, and others are also detected [3, 4, 5, 6, 7, 8, 9].
In traumatic primary mastoiditis, due to the formation of fissures and fractures, the relationships between the air-cell system are altered, multiple fractures of thin bony septa occur, small bone fragments form, and specific conditions are created for the spread of the inflammatory process. Extravasated blood from bone injury provides a favorable environment for infection development with subsequent resorption of bone fragments [1, 10].
In secondary mastoiditis, the main pathogenetic link is insufficient drainage of the purulent focus in the middle ear. The causes of insufficient drainage include: delayed drainage of the tympanic cavity associated with delayed spontaneous rupture of the tympanic membrane or failure to perform paracentesis in AOM; high location of the tympanic membrane perforation and its small size in chronic suppurative otitis media; obstruction to the outflow of secretion from the middle ear air-cell system due to closure of the communication between the air cells, antrum, and tympanic cavity by inflamed and thickened mucosa [1, 11].
Risk factors for the development of secondary mastoiditis include: age under two years, recurrent acute otitis media, incomplete pneumatization of the mastoid process, and presence of comorbid conditions leading to immunosuppression [2, 12, 16].
Acute mastoiditis generally occurs due to prolonged delayed outflow of inflammatory exudate from the middle ear cavities, persistent pressure elevation in the mastoid cells causing mucosal necrosis and spread of inflammation to bone structures. Most often, bone destruction develops in the region of the mastoid cortex, resulting in a subauricular/subperiosteal abscess in the retroauricular region, less frequently forming in the area of the posterior bony wall of the external auditory canal (also the anterior wall of the mastoid process) with skin detachment and fistula formation. Destruction in the area of the squamous part of the temporal bone leads to squamitis, and involvement of the temporal bone pyramid results in petrositis. If the bone destruction process directs toward the middle or posterior cranial fossa and the inflammation spreads into the cranial cavity, severe intracranial complications develop (meningitis, brain and cerebellar abscesses, thrombophlebitis of the venous sinuses, sepsis) [9, 10, 12, 13, 14].
The following stages of the inflammatory process development in the mastoid process are distinguished in mastoiditis:
1) Exudative stage. Lasts the first 7-10 days of the disease, during which inflammation of the mucous (endosteal) lining of the mastoid cells develops. Due to mucosal edema, the openings of the cells close, and the cells become isolated from the mastoid antrum. Communication between the mastoid antrum and the tympanic cavity is also disrupted. Cessation of ventilation of the antrum and mastoid cells leads to air rarefaction with vascular dilatation and hyperemia followed by transudation. The mastoid cells fill with inflammatory seropurulent or purulent exudate. This results in the formation of multiple closed empyemas within the mastoid process. On temporal bone computed tomography at this inflammatory stage, the septa between veiled cells are still discernible [1, 2, 12, 14, 15, 16].
2) Proliferative-alterative stage (true mastoiditis). Usually forms on the 7-10th day of the disease (develops earlier in children). A combination of parallel-running productive (granulation tissue formation) and destructive (bone resorption with lacuna formation) changes occurs. These changes simultaneously take place not only in the bony walls but also in the bone marrow spaces and vascular channels. Progressive resorption of bone tissue leads to the destruction of bony septa between the mastoid cells; individual destroyed cell groups coalesce to form cavities of varying sizes filled with pus and granulation tissue, or a single large cavity [1, 2, 12, 14, 15, 16].
1.3 Epidemiology of the Disease or Condition
According to modern literature, the incidence of acute mastoiditis ranges from 1.2 to 6.1 cases per 100,000 children aged 0-14 years. Acute mastoiditis most commonly arises against the background of AOM [9, 12, 16, 17, 18, 19, 20]. In turn, the frequency of AOM in the structure of otolaryngological diseases is 15-20%, and among ear diseases reaches 65-70%. In the first year of life, more than 35% of children experience acute otitis media one to two times, and 7-8% three or more times. By the age of three, 71% of children have had AOM [9, 15, 21].
Mastoiditis can occur at any age, but most frequently develops in children under two years of age. According to domestic data, the frequency of antritis in newborns and infants ranges from 14 to 40% and increases with concurrent somatic diseases [16, 21, 22]. Before the advent of systemic antibacterial drugs, 20 to 50% of acute otitis media cases were complicated by acute mastoiditis. In the antibiotic era, the incidence of mastoiditis secondary to AOM decreased sharply, ranging from 0.4 to 5% according to various authors. Pneumococcal vaccination has also contributed to the decrease in the number of patients with acute mastoiditis [4, 23, 24, 25]. Following the inclusion of pneumococcal vaccination in the national immunization schedule, the annual incidence of acute mastoiditis in children under 2 years declined to 4.5 per 100,000, but by 2008 rose again to 8-12 cases per 100,000 population in developed countries. At the same time, studies of acute mastoiditis in the USA between 2000-2012 did not reveal an overall decrease in hospitalization rates for acute mastoiditis among individuals under 21 years of age [12, 18, 19, 20].
1.4 Features of Coding the Disease or Condition
H70 – Mastoiditis and related conditions
H70.0 – Acute mastoiditis
H70.1 – Chronic mastoiditis
H70.2 – Petrositis
H70.8 – Other mastoiditis and related conditions
H70.9 – Mastoiditis, unspecified
1.5 Classification of the disease or condition
By predominant localization of the inflammatory process in the process [1, 2, 25].
By clinical course (acute and chronic) [1, 2, 27].
1.6 Clinical presentation of the disease or condition
General symptoms: deterioration of general condition, fever. In children, general symptoms may manifest as lethargy, drowsiness, irritability, and decreased appetite. Local symptoms: progressive ear pain radiating to the temple and occiput. Increased purulent discharge from the ear (this symptom may be absent due to blockade of the aditus ad antrum), tenderness upon pressure over the mastoid process, protrusion of the auricle, hyperemia and pastosity in the retroauricular region, sagging of the posterosuperior wall of the external auditory canal (EAC), hearing loss. Laboratory findings: leukocytosis, marked increase in erythrocyte sedimentation rate (ESR), elevation of blood C-reactive protein (CRP). These changes are not specific for acute mastoiditis, but they complement the clinical picture of the disease [1, 2, 12, 16].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria for mastoiditis:
1) Complaints of ear and retroauricular pain, headache, malaise, fever.
2) History of acute otitis media, chronic suppurative otitis media, or temporal bone trauma.
3) Physical examination findings: protrusion of the auricle, hyperemia and pastosity in the retroauricular region, painful palpation and percussion (in auditory pathology) of the mastoid process.
4) Findings from auditory organ examination (otoscopy): sagging of the posterosuperior wall of the external auditory canal.
5) Results of computed tomography (CT) of the temporal bone: impaired pneumatization of middle ear structures and presence of bone-destructive changes [1, 2, 8, 9, 12, 26].
2.1 Complaints and Anamnesis
Patients complain of fever, deterioration of general condition, hearing loss, headache, ear and retroauricular pain, protrusion of the auricle, and swelling and redness of the skin in the retroauricular region. In children, lethargy, drowsiness, irritability, and decreased appetite are noted. Chronic mastoiditis has a specific course, as the patient's general condition may not be compromised. Such patients complain of intermittent spontaneous pain, especially at night, and possible hearing loss.
Patients have a history of prior AOM/CSOM/temporal bone trauma [1, 2, 16, 28].
2.2 Physical Examination
It is recommended that all patients with symptoms of mastoiditis undergo an initial consultation (examination) by an otorhinolaryngologist to establish a diagnosis and determine treatment tactics [1, 2, 15, 16, 28, 29, 30].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: auditory organ examination (otoscopy) reveals: narrowing of the external auditory canal (EAC) due to sagging of the posterosuperior wall, skin hyperemia of the sagging part of the EAC; hyperemia, infiltration, bulging of the tympanic membrane. If tympanic membrane perforation is present – profuse suppuration and pulsating light reflex; however, absence of suppuration is also possible due to a block of the aditus ad antrum. In the retroauricular region: soft tissue pastosity and skin hyperemia over the projection of the mastoid process, smoothing of the skin fold at the site of auricle attachment, protrusion of the auricle. Attention should also be paid to facial symmetry and mimic musculature function. In acute mastoiditis, facial nerve palsy is possible due to edema of the myelin perineurium and nerve compression in the facial canal.
Atypical forms of mastoiditis may develop with varying degrees of mastoid process pneumatization.
When zygomaticitis develops – soft tissue edema in the projection of the zygomatic process extending to the cheek and eyelid.
Petrositis is characterized by Gradenigo's triad: retroorbital pain (irritation of the ophthalmic branch of the trigeminal nerve), diplopia – double vision (ipsilateral abducens nerve palsy), and symptoms of middle ear inflammation.
Bezold's mastoiditis – torticollis toward the affected side, skin edema and tenderness along the sternocleidomastoid, digastric, splenius capitis, and longissimus capitis muscles.
Orleans' mastoiditis – formation of an infiltrate around the attachment of the sternocleidomastoid muscle, pus breaks through dehiscences and vascular foramina onto the outer surface of the mastoid process tip without forming an abscess, pain upon head turning without torticollis (myositis) is characteristic, pressure on the infiltrate does not increase ear discharge.
Citelli's mastoiditis – involvement of the angular cells of the mastoid process with sigmoid sinus thrombosis, characterized by painful head turns, pain upon palpation of the posterior border of the sternocleidomastoid muscle, while the tip of the mastoid process remains free upon palpation.
Moure's mastoiditis – purulent process from the tip of the mastoid process breaks into the neck tissues and parapharyngeal space, characterized by dysphonia, foreign body sensation in the pharynx, swelling in the anterior part of the lateral neck surface, sharp tenderness upon pressure on the sternocleidomastoid muscle below the mastoid tip, and pharyngoscopy reveals infiltration/bulging of the lateral and posterior pharyngeal walls [1, 2, 25, 29, 31, 32, 33].
2.3 Laboratory Diagnostics
It is recommended to perform a complete blood count (CBC) with differential and test the serum C-reactive protein level in all patients with symptoms of mastoiditis to assess their general condition and the severity of the inflammatory process [1, 8, 15, 16].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: blood tests reveal neutrophilic leukocytosis with a left shift, elevated ESR, moderate anemia, and elevated CRP [20].
It is recommended to perform microbiological (culture) examination of ear discharge for aerobic and facultatively anaerobic microorganisms with determination of antimicrobial drug susceptibility in all patients with symptoms of mastoiditis to select adequate therapy [3, 4, 7, 19, 23].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
2.4 Instrumental Diagnostics
It is recommended to perform hearing examination using a tuning fork and/or speech audiometry in patients older than 7 years with suspected mastoiditis to diagnose hearing impairment [1, 12, 16].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform computed tomography of the temporal bone in all patients with symptoms of mastoiditis to diagnose bone-destructive and inflammatory changes [1, 2, 26, 30, 34, 35].
GCR BESL 2Level of recommendation evidence B for the pediatric population, C for the adult population (level of data certainty – 2 for the pediatric population, 4 for the adult population)
Comments: temporal bone CT allows assessment of the state of all anatomical structures of the temporal bone. Attention is drawn to impaired pneumatization of middle ear structures, as well as the presence of bone-destructive changes within it. If technical capabilities for temporal bone CT are lacking, temporal bone radiography in Mayer and Schüller projections may be performed [1, 15, 17].
It is recommended to perform computed tomography of the temporal bone with intravenous bolus contrast enhancement when intracranial complications are suspected [2, 27, 30, 35, 36, 49].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.5 Other Procedures
It is recommended that all patients with symptoms of mastoiditis undergo an initial consultation (examination) by a neurologist to rule out complications [1, 2, 15, 29, 30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Conservative treatment should be initiated immediately after diagnosis. The goals of conservative treatment for mastoiditis are eradication of the pathogen, localization of the inflammatory process and prevention of its spread beyond the temporal bone; alleviation of subjective and objective symptoms; and prevention of permanent hearing impairment [1, 2, 3, 4, 5].
It is recommended to administer systemic antibacterial therapy with penicillin combinations, including beta-lactamase inhibitor combinations (ATC: J01CR) – amoxicillin + [clavulanic acid]** or third-generation cephalosporins (ATC: J01DD) – cefotaxime**, ceftriaxone** in all patients with symptoms of mastoiditis to sanitize the infection focus and prevent purulent-septic complications [4, 15, 23, 37, 38, 39, 41, 42].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: antibiotic therapy must be initiated without waiting for the results of microbiological (culture) examination of ear discharge for aerobic and facultatively anaerobic microorganisms with pathogen identification and susceptibility testing to antimicrobial chemotherapeutic drugs. Systemic antibacterial drugs in adults and children must be administered parenterally.
Amoxicillin + [Clavulanic acid]** (ATC J01CR02) is used intravenously in adults and children over 12 years of age or weighing 40 kg or more at 1 g (amoxicillin component) 3 times a day; in children aged 3 months to 12 years weighing less than 40 kg at 25 mg/kg (amoxicillin component) 3–4 times a day for 5–14 days. Cefotaxime** (ATC: J01DD01) is administered intravenously or intramuscularly every 12 hours in adults and children over 12 years of age and weighing 50 kg or more at 1.0–2.0 g, with the dose varying depending on the severity of the infection, pathogen susceptibility, and the patient's condition; in children under 12 years of age and weighing under 50 kg at 100–150 mg/kg/day intravenously or intramuscularly divided into 2–4 doses for 7–10 days; in neonates − 50 mg/kg/day intravenously or intramuscularly divided into 2–4 administrations. Ceftriaxone** (ATC: J01DD04) is prescribed to adults and children over 12 years of age ≥ 50 kg at 1.0–2.0 g every 24 hours, to children under 12 years of age < 50 kg at 20–80 mg/kg/day once daily, and to neonates (under 14 days) at 20–50 mg/kg/day intravenously or intramuscularly for 7–14 days [4, 38, 40, 41, 46].
It is recommended to administer systemic antimicrobial therapy with glycopeptide antibacterial drugs (ATC J01XA) — Vancomycin** in patients with symptoms of mastoiditis upon isolation of MRSA and/or intolerance to beta-lactam antibacterial drugs, penicillins, or Carbapenems (ATC J01DH) — #Meropenem** in children at a dose of 60 mg/kg/day divided into 3 doses every 8 hours intravenously when Ps. aeruginosa or strains resistant to beta-lactam antibacterial drugs, penicillins (ATC J01C) and other beta-lactam antibacterial drugs (ATC J01D) are isolated, in order to sanitize the focus of infection and prevent purulent-septic complications [4, 37, 38, 40, 42, 58, 59].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: in cases of isolation of MRSA, Streptococcus spp. (including strains resistant to broad-spectrum penicillins), and/or intolerance to beta-lactam antibacterial drugs, penicillins, or in case of intolerance or lack of response to treatment with other systemic antibacterial drugs, Vancomycin** (ATC J01XA01) may be the drug of choice. In adults and children over 12 years of age, the drug should be administered as an IV infusion at 2 g per day (0.5 g every 6 h or 1 g every 12 h). Each dose should be administered at a rate of no more than 10 mg/min and over at least 60 min. The maximum single dose is 1 g, and the maximum daily dose is 2 g. In children from 1 month to 12 years of age, the drug should be administered IV at a dose of 10 mg/kg every 6 h. Each dose should be administered over at least 60 min. The recommended daily dose is 40 mg/kg [4, 8, 17, 39, 40, 41, 42].
It is recommended to prescribe drugs from the group of other analgesics and antipyretics (ATC: N02B) — paracetamol** — and the group of non-steroidal anti-inflammatory and antirheumatic drugs (ATC: M01A) — ibuprofen**, diclofenac**, ketorolac**, ketoprofen**, lornoxicam, dexketoprofen** in pharmaceutical forms and dosages according to the instructions for use, for patients diagnosed with mastoiditis presenting with pain syndrome and/or fever, including after surgical treatment (Appendix A3.2, A3.3) [47, 48, 60, 63].
For paracetamol**, ibuprofen**, diclofenac**, ketorolac**, ketoprofen**, lornoxicam, and dexketoprofen** in adult and pediatric populations, the strength of recommendation is C (level of evidence – 5)
For the use of lornoxicam and diclofenac** in adults – the strength of recommendation is B (level of evidence – 2)
It is recommended to use antimicrobial agents locally (ATC: S02AA) in the form of ear drops — ofloxacin** in adults and children over 15 years of age, and rifamycin** in children diagnosed with mastoiditis if there is a tympanic membrane perforation, as well as in the postoperative period through a paracentesis opening/tympanostomy drainage tube, for local antibacterial therapy and to improve the outflow of pathological discharge from the tympanic cavity (continuation of treatment for acute otitis media as the primary cause of mastoiditis) [4, 16, 61].
SOR CStrength of recommendation C (level of evidence – 5 for ofloxacin** and rifamycin** in children, 4 for ofloxacin** in adults)
Comments: in adults and children over 15 years of age, ofloxacin**-based ear drops (ATC S02AA16) are administered through a tympanic membrane perforation or tympanostomy drainage tube at 5 drops 2 times a day for 10 days; in children, rifamycin**-based ear drops (ATC S02AA12) are administered at 3 drops 3 times a day for 7 days.
It is recommended to prescribe decongestants and other nasal preparations for topical use (ATC code: R01A) — oxymetazoline, xylometazoline** in accordance with the instructions for use — to all patients with symptoms of mastoiditis to restore auditory tube function (continuation of treatment for acute otitis media as the primary cause of mastoiditis) [9, 16, 43, 62].
SOR CLOE 5Strength of recommendation C (level of evidence – 5 for the pediatric population, 4 for the adult population)
Comments: the duration of use of nasal decongestants and other topical nasal preparations should not exceed 7 days. Special caution must be exercised when prescribing decongestants and other topical nasal preparations to children. Oxymetazoline (ATC: R01AA05) can be prescribed to infants under one year of age: under 4 weeks of age, 1 drop of a 0.01% solution in each nasal passage 2–3 times a day; from 5 weeks to 1 year of age, 1–2 drops of a 0.01% solution in each nasal passage 2–3 times a day; from 1 to 6 years of age, 1–2 drops of a 0.025% solution in each nasal passage 2–3 times a day; adults and children over 6 years of age should use 1–2 drops of a 0.05% solution in each nasal passage 2–3 times a day. Xylometazoline** (ATC: R01AA07) 0.05% solution can be prescribed to children aged 2 to 6 years at 1–2 drops in each nasal passage 1–3 times a day; 0.1% solution can be prescribed to children over 6 years of age and adults at 2–3 drops in each nasal passage 2–3 times a day [9, 43, 46].
3.2 Surgical Treatment
Surgical treatment performed on an emergency basis is indicated in the management of mastoiditis/antritis. The goal is to ensure the most rapid and effective outflow of pathological exudate from the middle ear cavities and to prevent its further spread beyond the mastoid process [4, 8, 9, 21, 41, 44, 45, 46, 49, 50].
It is recommended to perform tympanic membrane paracentesis/tympanostomy and drainage of the tympanic cavity in patients with mastoiditis who have an intact tympanic membrane, in order to ensure the timely outflow of purulent exudate from the tympanic cavity and prevent the development of intracranial complications [17, 23, 41, 44].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: in the absence of a spontaneous tympanic membrane perforation of sufficient size, paracentesis/tympanostomy and drainage of the tympanic cavity must be performed. Paracentesis/tympanostomy and drainage of the tympanic cavity is the first stage of treatment for uncomplicated acute mastoiditis/antritis. To avoid rapid closure of the tympanic membrane perforation, to facilitate the instillation of ear drops into the tympanic cavity, and to ease the outflow of discharge from the middle ear, it is preferable to place a tympanostomy drainage tube (if conditions for its placement are met). If there is no positive clinical response within 48–72 hours, the second stage of surgical treatment — antromastoidectomy/antrodrainage (antrotomy) — must be performed for complete sanitation and drainage of the mastoid process [8, 17, 41].
It is recommended to perform antromastoidectomy, antrodrainage (antrotomy) in all patients diagnosed with mastoiditis/antritis in case of ineffectiveness of prior treatment, in order to prevent the spread of the inflammatory process beyond the temporal bone and the development of complications [8, 17, 18, 21, 23, 41, 51, 52, 53].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: indications for antromastoidectomy, antrodrainage (antrotomy): 1) lack of response to conservative treatment and tympanic membrane paracentesis/tympanostomy and tympanic cavity drainage within 48–72 hours from the start of treatment; 2) presence of a subperiosteal abscess/neck abscess; 3) signs of infection spreading to the meninges or the presence of other intracranial complications; 4) otogenic sepsis; 5) a sluggish process (lasting more than a month) in the mastoid process with radiographic evidence of tissue destruction and patient complaints.
The surgery is performed under combined endotracheal anesthesia. It is advisable to carry out the intervention under the control of an operating microscope. Opening of the mastoid process in infants is limited to the mastoid antrum due to developmental features. In children over one year of age and adults, surgical revision of the entire cellular system of the mastoid process is mandatory. After opening the antrum and surrounding cells, it is necessary to ensure the patency of the aditus ad antrum. If there was a complication in the form of a subperiosteal abscess, or if there is reason to believe that the inflammatory process in the mastoid process may continue, the retroauricular wound is not completely sutured; instead, only one or two sutures are placed in the upper and lower corners, and the wound is managed by open-wound technique. In other cases, a silicone drainage tube is placed into the antrum, and the wound is sutured entirely. Daily dressings are performed in the postoperative period. The silicone drainage tube is removed on days 5–7 after surgery. The open wound is sutured after complete cleansing of the postoperative cavity [4, 16, 41].
3.3 Other Treatment
Not performed.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to perform follow-up pure-tone audiometry (for patients older than 7 years) or play audiometry (for children aged 3 to 7 years) or otoacoustic emission testing (for children under 3 years) one month after recovery in all patients who have undergone mastoiditis to rule out/confirm hearing loss [54, 55, 56, 57].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: if hearing loss is detected, an initial consultation (examination) by an audiologist-otorhinolaryngologist is required.
5. Prevention and Dispensary Observation
Prevention of mastoiditis is closely related to the prevention of acute otitis media, diseases of the nose, paranasal sinuses, and lymphopharyngeal ring, as well as the need for qualified treatment of chronic otitis media and timely surgical treatment of the middle ear, nasal cavity, paranasal sinuses, nasopharynx, and pharynx when indicated [1].
Dispanserization (clinical follow-up) of patients who have had mastoiditis is not required.
6. Organization of Medical Care
All patients with mastoiditis, regardless of the etiology of the disease and the stage of the inflammatory process, are subject to emergency hospitalization in a medical organization providing specialized medical care in the profile of «otorhinolaryngology».
Indications for discharging a patient from a medical organization:
normalization of the general condition (absence of fever, absence of signs of intoxication),
normalization of parameters in the complete blood count (CBC) and general biochemical blood test,
absence of ear discharge.
7. Additional Information
In children, frequent nasal breathing impairment, wide and short straight auditory tubes, the presence of embryonic myxoid tissue in the tympanic cavity, along with the high position of the mastoid antrum, create conditions for poor aeration of the middle ear and difficult drainage. This promotes the development of antritis even at an early stage of acute otitis media, especially in newborns. Of decisive importance in the development and course of antritis and mastoiditis are the body's reactivity (reduced local and general immunity), infectious diseases, prematurity, perinatal pathology, nutritional disorders (hypo- and paratrophies), and endocrine diseases [16, 46].
Technique of antromastoidectomy and antral drainage.
The soft tissue incision is made from top to bottom down to the apex of the mastoid process, 5 mm away from the line of attachment of the auricle to the cranium. Simultaneous incision of all layers of soft tissue and periosteum down to the bone is possible; however, layered soft tissue incision allows the surgeon to perform stepwise hemostasis as needed and avoid major blood loss. Trepanation of the mastoid process is performed within the boundaries of Schchipachev's (Shrapnell's / MacEwen's / Schiff's - wait, Shchipachev/Shipo is Shipa's triangle = Spines's triangle/suprameatal triangle) Shrapnell's? No, Сборник/Шипо is MacEwen's triangle / triangle of Shchipachev (Шипо = Shipo's triangle / suprameatal triangle). Let's use «suprameatal triangle (triangle of Shipo)» or simply «Shchipachev's triangle»? In Russian ENT, «треугольник Шипо» is Shipo's triangle (suprameatal triangle). Let's write «Shipo's triangle» strictly adhering to its boundaries. The antrum is found deep and anteriorly in the projection of Trautmann's triangle. With any form of mastoiditis, one should not limit oneself to merely opening the antrum; a mandatory surgical revision of the mastoid cellular system is required. After thorough inspection of the surgical field and removal of all pathologically altered tissues and bone fragments, the cavity is washed, a silicone drainage tube is placed in the antrum, and the wound is sutured completely. If there was a complication in the form of a subperiosteal abscess, or if there is reason to believe that the inflammatory process in the mastoid process may continue, the wound is not completely sutured, but only one or two sutures are placed in the upper and lower corners.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criterion | Evaluation of compliance Yes/no |
|---|---|---|
1 | All patients with symptoms of mastoiditis underwent an initial consultation (examination) by an otorhinolaryngologist | Yes/no |
2 | All patients with symptoms of mastoiditis were prescribed systemic antibacterial therapy with drugs from the penicillin combination group, including combinations with beta-lactamase inhibitors (ATC: J01CR) – amoxicillin + [clavulanic acid]** or third-generation cephalosporins (ATC: J01DD) – cefotaxime**, ceftriaxone** | Yes/no |
3 | Patients with symptoms of mastoiditis with MRSA isolation and/or intolerance to beta-lactam antibacterials and penicillins were prescribed Vancomycin**, or upon isolation of Ps. aeruginosa or strains resistant to beta-lactam antibacterials, penicillins (ATC J01C) and other beta-lactam antibacterials (ATC J01D), children were prescribed #Meropenem** at a dose of 60 mg/kg/day divided into 3 doses every 8 hours intravenously for the purpose of sanitizing the infection focus and preventing purulent-septic complications | Yes/no |
4 | Patients with mastoiditis with intact tympanic membrane underwent myringotomy (tympanentesis) / tympanostomy tube insertion and drainage of the tympanic cavity | Yes/no |
5 | Patients with mastoiditis/antritis in case of ineffectiveness of previously performed treatment underwent antromastoidectomy, antral drainage (antrotomy) | Yes/no |
References
Show references
National Guidelines. Ed. by V.T. Palchun. M.: GEOTAR-Media, 2014: 624 p.
Palchun V.T., Kryukov A.I., Magomedov M.M. Otorhinolaryngology. Textbook. 4th edition. M.: Geotar-Media, 2022: 599 p. (everything according to the textbook).
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Appendix A1. Working Group Composition
Egorov V.I., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Mileshina N.A., MD, PhD – not a member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Shakhov A.V., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Yunusov A.S., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Svistushkin V.M., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Artyushkin S.A., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Golovanov A.E., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Polunin M.M., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Geppe N.A., MD, PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Pustovit O.M., PhD (Medicine) – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of the clinical guidelines:
general practitioner (family physician);
otorhinolaryngologist;
otorhinolaryngologist-audiologist;
senior physician of the ambulance station (department);
emergency physician;
pediatrician;
medical school students;
residents;
general practitioner / physician.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference method control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing levels of recommendation credibility (LRC) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
Level of Evidence / Strength of Recommendation | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high satisfactory methodological quality, and their conclusions regarding the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high satisfactory methodological quality and/or their conclusions regarding the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines
The clinical guideline update mechanism provides for systematic revision at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or when justified additions/comments to previously approved clinical guidelines arise, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Order of the Russian Ministry of Health No. 905n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile of 'Otorhinolaryngology';"
Order of the Ministry of Health and Social Development of Russia No. 366n dated April 16, 2012, "On Approval of the Procedure for Providing Pediatric Care;"
State Register of Medicines: URL: https://grls.rosminzdrav.ru
Order of the Ministry of Health of Russia No. 205n dated May 2, 2023, "On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers";
Order of the Ministry of Health and Social Development of Russia No. 541n dated July 23, 2010, "On Approval of the Unified Qualification Handbook of Positions of Managers, Specialists and Employees, Section 'Qualification Characteristics of Employee Positions in Healthcare';"
Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation' regarding Clinical Guidelines;"
Order of the Russian Ministry of Health dated February 28, 2019, No. 103n "On Approval of the Procedure and Deadlines for the Development of Clinical Practice Guidelines, Their Revision, the Standard Template of Clinical Practice Guidelines, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Practice Guidelines";
Order of the Ministry of Health of Russia No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services";
Order of the Russian Ministry of Health No. 1094n dated November 24, 2021, "On Approval of the Procedure for Prescribing Medicinal Products, Prescription Forms for Medicinal Products, the Procedure for Issuing, Recording, and Storing the Said Forms, Forms of Prescriptions Containing Assignments of Narcotic Drugs or Psychotropic Substances, the Procedure for Their Manufacture, Distribution, Registration, Accounting, and Storage, as Well as the Rules for Issuing Prescription Forms, Including in the Form of Electronic Documents;"
Federal Law No. 61-FZ dated April 12, 2010, "On the Circulation of Medicines."
Appendix A3.1 Recommended doses and regimens of analgesic and anti-inflammatory therapy in adults with mastoiditis
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
|---|---|---|---|---|
Paracetamol** (ATC: N02BE01) (prescribed when intravenous administration is clinically justified and/or administration via other routes is impossible) | for body weight > 50 kg – 1 g, IV infusion over 15 min. | minimum interval 4 h | 4 g | 5-7 days |
Diclofenac** (ATC: M01AB05) | 75 ml IM | 12-24 h | 150 mg | 2 days |
Ketorolac** (ATC: M01AB15) | 30 mg IV, IM | 8 h | 60 mg (for patient weight less than 50 kg) – 90 mg (for patient weight greater than 50 kg) | 2 days |
Ketoprofen** (ATC: M01AE03) | 100 mg IV, IM | 12-24 h | 200 mg | no more than 2 days |
Lornoxicam (ATC: M01AC05) | 8 mg IV, IM | 12 h | 16 mg | minimum effective dose for the shortest possible course. |
Dexketoprofen** (ATC: M01AE17) | 50 mg IV, IM | 8–12 h | 150 mg | 2 days |
Appendix A3.2 Recommended doses and regimens of analgesic and anti-inflammatory therapy in children with mastoiditis
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
|---|---|---|---|---|
Paracetamol** (IV) (ATC: N02BE01) (prescribed when intravenous administration is clinically justified and/or administration via other routes is impossible) | IV infusion over 15 minutes: 10-50 kg – 15 mg/kg up to 4 times a day; < 10 kg – 7.5 mg/kg up to 4 times a day > 50 kg – 1000 mg up to 4 times a day | 4 h | > 33 - ≤ 50 kg – ≤ 60 mg/kg, but no more than 3 g; >10 - ≤ 33 kg – ≤ 60 mg/kg, but no more than 2 g; ≤ 10 kg – ≤ 30 mg/kg > 50 kg – 4 g | 5-7 days |
Paracetamol** (oral / per os) (ATX: N02BE01) | tablets: from 12 years – 0.5-1 g; 9 - 11 years – 0.5 g; 6-8 years – 250 mg; suspension for oral administration: from 3 months to 12 years – 10-15 mg/kg up to 4 times a day | 6 h | from 12 years – 4 g; under 12 years – < 60 mg/kg | 3 days |
Paracetamol** (rectal suppositories (for children) (ATX: N02BE01) | from 12 years – 0.5 g under 12 years – 10-15 mg/kg | 6 h | from 12 years – 4 g; under 12 years – < 60 mg/kg | 3 days |
Ibuprofen** (oral/per os) (ATC: M01AE01) | tablets: from 12 years – 200 mg; suspension for oral administration: 3–6 months (child weight 5 to 7.6 kg) – 50 mg up to 3 times/day, 6–12 months (child weight 7.7–9 kg – 50 mg up to 3–4 times/day; 1–3 years (child weight 10–16 kg) – 100 mg up to 3 times/day; 4–6 years (child weight 17–20 kg) – 150 mg up to 3 times/day; 7–9 years (child weight 21–30 kg) – 200 mg up to 3 times/day; 10–12 years (weight 31–40 kg) – 300 mg up to 3 times/day. | 8 h | from 12 years – 1 g; 10–12 years – 900 mg; 7–9 years – 600 mg; 4–6 years – 450 mg; 1–3 years – 300 mg; 6–12 months – 200 mg; 3–6 months – 150 mg | 3 days |
Ibuprofen** (rectal suppositories (for children)) (ATC: M01AE01) | 3–9 months (6–8 kg) – 60 mg 9–24 months – 60 mg | 8 h 6 h | 3–9 months – 180 mg 9–24 months – 240 mg | no more than 3 days |
Ketoprofen** (ATC: M01AE03) | from 15 years – 100 mg IV, IM | 12-24 h | 200 mg | no more than 2 days |
Ketoprofen (granules for oral solution /per os) (ATX: M01AE03) | > 6–14 years – 40 mg 14–18 years – 80 mg | 8 h | 6–14 years – 120 mg > 14 years – 200 mg |
Clarification of notes
** – a medicinal product included in the List of Vital and Essential Drugs for medical use for 2020 (Decree of the Government of the Russian Federation No. 3867-r dated December 18, 2025
# – off-label use (outside the indications registered in the drug instructions) is carried out by decision of the medical commission, with the permission of the Local Ethics Committee of the medical organization (if any), subject to the signed informed consent of the parents (legal representative) and the patient over 15 years of age.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Ear pain and retroauricular pain, protrusion of the auricle, and skin redness in the retroauricular region may be signs of mastoiditis. In this case, the patient should immediately consult an otorhinolaryngologist.
Mastoiditis is an inflammatory condition that requires emergency hospitalization in a medical organization providing specialized medical care in the field of otorhinolaryngology. If timely treatment is not initiated, intracranial complications and life-threatening conditions may develop.
With timely treatment, the prognosis is favorable.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.