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ACUTE MASTOBDITIS                                 333

Fever is not marked in adults but may be high in children, in whom a rising
pulse rate is a potential danger signal. Deafness is present in most cases
but varies in severity. Local signs vary with the stage and extent of the infec-

In the case of periostitis palpation over the mastoid area may reveal thick-
ening of the periosteum on the affected side. Later there is oedema of the
soft tissues with displacement of the auricle downwards and outwards and
the erection of the auricle is seen more easily from behind the patient. If a
subperiosteal abscess forms there is a fluctuant swelling behind the ear
(Fig. 171). Narrowing of the external meatus due to sagging of the postero-
superior meatal wall is a significant finding on otoscopy which may reveal
a perforated drumhead with pulsating discharge or an intact one which has
a thickened or full appearance. Patients generally look ill and feel off colour
and disinterested. Those with pain and systemic disturbance are more
anxious and aware of their illness.

DIAGNOSIS. In some cases difficulty may arise in distinguishing between
mastoiditis and furunculosis of the posterior meatal wall with cellulitis (see
p. 304). Considerable help in arriving at a diagnosis of mastoiditis may be
obtained from radiography of the mastoids by comparing films of the
affected and unaffected sides in different views of the temporal bone.
Anatomical asymmetry of the mastoid process is found in 12 per cent of
cases. The radiograph shows the type of mastoid process and the extent
of cellular development (Fig. 173, A). In early cases of mastoid infection,
slight blurring of the cellular outlines is present on the affected side and
the outline of the bony plate of the lateral sinus becomes more prominent.
Increasing opacity with pus formation is followed by loss of cellular out-
lines or trabeculation, by destruction of bone proceeding eventually to
formation of an abscess cavity. The radiological appearances should at all
stages be correlated with the clinical manifestations and follow-up radio-
graphy is often necessary.

Blood examination generally shows a polymorphonuclear leucocytosis
and the erythrocyte sedimentation rate is increased except possibly in those
patients who have had antibiotic treatment.

TREATMENT. The incidence of acute mastoiditis has been greatly reduced
since the advent of antibiotic treatment particularly with penicillin. The
majority of cases of acute suppurative otitis media now resolve by early
and adequate treatment with parenteral penicillin combined if necessary
with paracentesis. The presence of pus in the middle ear may be associated
with increased tension requiring relief by surgical drainage otherwise some
permanent loss in hearing may result.

When the clinical features of mastoiditis develop the patient should be
confined to bed and antibiotic administration commenced. Until pus from
the ear is available for bacteriological examination, penicillin should be
given by intramuscular injection starting with 1 million units (benzyl peni-
cillin) followed by 500000 units 6-hourly. Lack of improvement in the
patient's condition in 48 hours is an indication for a change of antibiotic
or a cortical mastoidectomy.

The indications for the cortical mastoid operation, also known as Schwartze's
operation, are: (1) Continued pain and mastoid tenderness for more than
2 or 3 days despite antibiotic therapy in full dosage and adequate drainage