Mastoiditis - Symptoms

Mastoiditis is characterized by subjective and objective symptoms. Subjective symptoms include spontaneous pain associated with the involvement of the periosteum behind the auricle in the mastoid process area in the inflammatory process, radiating to the parietal, occipital region, orbit, alveolar process of the upper jaw; much less often, the pain spreads to the entire half of the head. A characteristic sensation of pulsation in the mastoid process, synchronous with the pulse, is typical. Objective symptoms include acute onset with fever, deterioration of the general condition, intoxication, and headache. Prominence of the auricle, swelling and redness of the skin in the retroauricular region, and smoothing of the retroauricular skin fold along the line of attachment of the auricle are pronounced. Fluctuation and sharp pain on palpation are noted during the formation of a subperiosteal abscess. As a result of the periosteum being involved in the inflammatory process, the pain radiates along the branches of the trigeminal nerve to the temple, parietal region, occiput, teeth, and orbit. In advanced cases, the subperiosteal abscess, exfoliating soft tissues, can spread to the temporal, parietal, and occipital regions. Thrombosis of the vessels feeding the outer cortical layer causes bone necrosis with a breakthrough of pus through the periosteum and soft tissues, forming an external fistula. In young children, pus often breaks through the squamomastoid fissure that has not yet closed. The formation of a subperiosteal abscess depends on the structure of the mastoid process, especially on the thickness of the cortical layer.

Otoscopy is characterized by the symptom of overhanging of the posterior superior wall of the bony part of the external auditory canal, which is also the anterior wall of the mastoid cavity (Schwartze's symptom).

The overhang of the posterosuperior wall is a consequence of periostitis of the anterior wall of the mastoid cavity and the pressure of the pathological contents of the entrance to the mastoid cave and the cave itself; inflammatory changes in the eardrum are expressed, corresponding to acute otitis or exacerbation of chronic purulent otitis media, in the presence of perforation of the eardrum - profuse suppuration and a pulsating reflex. The amount of purulent discharge significantly exceeds the volume of the tympanic cavity, which indicates the presence of a source of pus other than the tympanic cavity, after careful toilet, purulent discharge quickly fills the lumen of the external auditory canal. At the same time, hearing is impaired according to the conductive chip. Changes in the hemogram corresponding to the inflammatory process are noted.

The cells in a well-pneumatized mastoid process have a typical group arrangement: zygomatic, angular, apical, threshold, perisinus, perifacial, perilabyrinthine. According to the degree and nature of their pneumatization, the purulent process spreads to certain cell groups with the development of typical symptoms. When the perisinus cells are affected, periphlebitis, phlebitis and thrombophlebitis of the sigmoid sinus develop; destruction of the perifacial cells is dangerous in terms of the development of facial nerve paresis (in acute mastoiditis, the cause of paresis is mainly toxic edema of the perineural myelin sheaths and compression of the facial nerve in the fallopian canal; in mastoiditis against the background of exacerbation of chronic otitis media, carious destruction of the wall of the facial nerve canal predominates). Apical mastoiditis constitutes a special group. The direction of the spread of pus and, accordingly, the clinical symptoms depend on the location of the pus breakthrough (through the outer or inner surface of the apex of the mastoid process).

In this regard, the following forms of apical mastoiditis are distinguished.

Bezold's mastoiditis.

In this form, pus breaks through the thin inner wall of the apex, flows down into the neck area and gets under the sternocleidomastoid, splenius muscle, longissimus capitis and deep fascia of the neck. Muscle-fascial formations make it difficult for pus to break through to the outside; a fluctuating infiltrate is formed on the lateral surface of the bodies, the contours of the apex of the mastoid process cannot be palpated. In this case, a forced position of the head is noted with a tilt to the side of the sore ear and forward, pain in the neck with irradiation to the shoulder area. The infiltrate is quite dense and does not often fluctuate; however, pressing on it causes an increase in purulent discharge from the ear, unlike Orleans mastoiditis. This is explained by the fact that the accumulation of pus is located under the deep cover of muscles and cervical fascia, which do not allow the pus to break through to the outside. Although the outer surface of the apex of the mastoid process is quite dense, and the thick cortical layer is still covered by a thick muscular-fascial aponeurosis, a breakthrough of pus is also possible on the outer surface of the apex of the mastoid process. This form of mastoiditis is dangerous in terms of the development of purulent mediastinitis, the spread of pus along the anterior surface of the cervical vertebrae with the formation of a retropharyngeal and lateral pharyngeal abscess and phlegmon of the neck.

Mastoiditis K.A. Orleanskiy apical, cervical external

In this form of mastoiditis, pus breaks through to the outer surface of the apex of the mastoid process with the development of a fluctuating infiltrate around the attachment of the sternocleidomastoid muscle with pronounced inflammatory changes in the parotid region, severe pain to palpation: independent pain occurs when turning the head due to myositis, there may be torticollis. It is believed that the breakthrough of pus occurs not by destruction of the outer cortical layer of the apex of the mastoid process, but as a result of penetration of pus through some preformed defects (remnants of an unhealed fissure, numerous openings of blood vessels, dehiscences): therefore, in contrast to the Bezold form of mastoiditis, pressure on the cervical infiltrate causes increased purulent discharge from the ear. The purulent exudate impregnates the soft tissues, but does not form an intra-aponeurotic muscle abscess.

Mastoiditis Mure

This form of mastoiditis is accompanied by a breakthrough of pus into the digastric fossa on the anterior-inferior surface of the apex of the mastoid process with subsequent spread to the posterior subparotid space, where the internal jugular vein with its bulb, IX, X, and XI cranial nerves, facial nerve, cervical sympathetic trunk and internal carotid artery are located. There is a risk of developing phlebitis of the bulb of the jugular vein, paresis of the corresponding cranial nerves and fatal erosive bleeding from the internal carotid artery. Pus under the digastric muscle also spreads towards the spine, mediastinum with the development of paravertebral lateropharyngeal or retropharyngeal abscesses. Clinically, local pain is determined by palpation of the lower surface of the apex of the mastoid process, contracture and resistance of the sternocleidomastoid and digastric muscles, swelling in the anterior part of the lateral surface of the neck, torticollis, sharp pain when pressing on the sternocleidomastoid muscle immediately below the apex, turning the head is difficult and painful. Symptoms from the pharynx are characteristic, along the spread of pus: swelling of the lateral or posterior wall of the pharynx, paratonsillar region, dysphonia, pain when swallowing radiating to the ear, patients complain of a sensation of a foreign body in the throat.

Petrosite

This most severe form of mastoiditis develops with pronounced pneumatization of the apex of the pyramid of the temporal bone. It also causes severe clinical symptoms - the so-called Gradenigo syndrome. Along with the clinical picture of mastoiditis, neuralgia of all three branches of the trigeminal nerve with severe pain syndrome is characteristic, arising due to compression of the inflamed periosteum of the Gasserian ganglion, located at the apex of the pyramid in the area of the trigeminal depression. Simultaneous damage to the abducens nerve is clinically manifested by diplopia. Less often, the oculomotor, facial, glossopharyngeal and accessory nerves are affected. Damage to the oculomotor nerve leads to drooping of the eyelids (ptosis) and limited mobility of the eyeball outward and downward. Combined damage to the III and VI cranial nerves causes complete immobility of the eyeballs (ophthalmoplegia), which in some cases can be a symptom of cavernous sinus thrombosis, complicating the course of petrositis. In rare cases, spontaneous emptying of the abscess occurs with a breakthrough into the tympanic cavity, or through the base of the skull into the nasopharynx with the development of a purulent abscess in this area, determined by posterior rhinoscopy.

Acute zygomatitis

This disease occurs when the inflammatory process moves to the cellular system of the zygomatic process and is characterized by spontaneous pain and tenderness when pressing in the area of the zygomatic process, swelling of the soft tissues in the same area, accompanied by a downward and outward displacement of the auricle, often with an intact mastoid process. Infiltration and swelling of the soft tissues often spread to the area of the corresponding eye, causing the eye slit to narrow. Otoscopically, zygomaticitis is characterized by a drooping of the upper wall of the bony section of the auditory canal.

Chitelevsky form of mastoiditis

It is caused by damage to the angular cells of the mastoid process, which are in direct contact through the vitreous plate of the posterior cranial fossa and multiple vessels with the sigmoid sinus, therefore this form is dangerous in terms of the development of periphlebitis, phlebitis, thrombophlebitis and perisinus abscess. In case of severe destruction of the angular cells, revision of the posterior cranial fossa is mandatory during the operation.

Kornerovsky form of mastoiditis

This particular form of mastoiditis results in the development of septicopyemia, but without thrombosis of the sigmoid sinus. The cause of septicopyemia in these cases is thrombosis of the small bone veins of the mastoid process.

Latent mastoiditis

This type is a special group of diseases characterized by a sluggish, slow course without pathognomonic symptoms for this disease. The development of the purulent process in the mastoid process occurs without the formation of exudate in the middle ear, without pronounced fever, without the occurrence of pain with pressure in the mastoid process. Only at later stages may pain appear when palpating the parotid region. Clinically, intermittent spontaneous pain is noted, especially at night, hearing loss, persistent hyperemia of the eardrum. The development of this form of mastoiditis in children and young people is facilitated by the so-called masking action of antibiotics, and in old age - senile osteosclerosis. At the same time, in the depths of the mastoid process, a destructive process develops sluggishly but persistently, which, if not diagnosed in a timely manner, after a more or less long period of time leads to sudden severe complications (labyrinthitis, facial nerve paresis, intracranial complications).

Mastoiditis complicating otomycosis

This form of the disease is characterized by a recurrent sluggish course, resistance to traditional drug therapy. However, its exacerbations can proceed rapidly with pronounced reactive processes, especially in the area of apical cells, and during surgery, quite serious changes are detected in the form of multiple mycotic foci. In adult patients with otomycosis, indications for surgical treatment are limited; in childhood, it is recommended to expand the indications for surgical sanitation to prevent the development of serious complications.

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