| Features | Treatment |
Uncomplicated acute mastoiditis | Typically a clinical diagnosis based on fever; otalgia; postauricular erythema, swelling, and tenderness; abnormal tympanic membrane; and protrusion of the auricle | Conservative management initially* |
Uncomplicated subacute (masked) mastoiditis | Fever, cough, ear pain, and tympanic membrane findings compatible with AOM; should be considered in children with AOM that is not responding to antibiotics | Conservative management initially* |
Acute or subacute mastoiditis with isolated facial nerve paralysis | Unilateral facial paralysis on the same side as the ear findings | Conservative management initially* |
Acute mastoiditis with subperiosteal abscess without other complications | Postauricular fluctuance or mass | Aggressive surgical management¶Δ |
Acute or subacute mastoiditis with CT evidence of coalescent mastoiditis | Loss of definition of the bony septae that define the mastoid air cells | Aggressive surgical management¶ |
Acute mastoiditis with suppurative complications, including ≥1 of the following: - Bezold abscess
- Osteomyelitis involving other parts of the skull
- Suppurative labyrinthitis
- Meningitis
- Subdural abscess
- Epidural abscess
- Brain abscess
- Cerebellar abscess
- Septic dural sinus thrombosis
| Signs that raise concern for a suppurative complication include high fevers, irritability, and focal neurologic findings; Bezold abscess is suggested by swelling and tenderness below the mastoid process and under the sternocleidomastoid muscle; most of these diagnoses are confirmed with imaging studies; meningitis is diagnosed with CSF analysis (including culture) | Aggressive surgical management¶◊ |