Chronic Mastoiditis

Chronic mastoiditis arises when chronic suppurative otitis media (CSOM) with or without cholesteatoma extends into the mastoid air cell system, producing osteitis, granulation tissue, and gradual destruction of trabecular bone. Common pathogens include Pseudomonas aeruginosa, Staphylococcus aureus, anaerobes, and polymicrobial flora; cholesteatoma adds keratin debris and matrix that further erodes bone.

Symptoms are persistent or intermittent foul-smelling otorrhea, conductive or mixed hearing loss, postauricular dull ache, dizziness from labyrinthine erosion, and occasional facial weakness. Examination shows a perforated tympanic membrane with otorrhea, retraction pocket with keratin debris in cholesteatoma, granulation tissue, and tenderness over the mastoid. Imaging with high-resolution temporal bone CT defines opacification, scutum erosion, ossicular destruction, and tegmen or sigmoid plate dehiscence; MRI with diffusion-weighted imaging detects residual or recurrent cholesteatoma.

Initial management includes aural toilet, topical fluoroquinolone drops, and treatment of granulation tissue. Definitive treatment is surgical: canal wall up (intact canal wall) mastoidectomy preserves anatomy but requires second-look procedures, while canal wall down mastoidectomy creates an exteriorized cavity that requires periodic cleaning but reduces recurrence. Reconstruction with cartilage and ossiculoplasty restores hearing. Complications include facial nerve paralysis, labyrinthitis, sigmoid sinus thrombosis, meningitis, and brain abscess.