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Mastoiditis

Mastoiditis is an infection of the mastoid process, the portion of the temporal bone of the skull that is behind the ear. It is usually caused by untreated acute otitis media (middle ear infection) and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries, most likely due to antibiotic treatment of otitis media before it can spread. It is treated with medications and/or surgery. If untreated, the infection can spread to surrounding structures, including the brain, causing serious complications. more...

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Features

Some common symptoms and signs of mastoiditis include pain and tenderness in the mastoid region, as well as swelling. There may be earaches or ear pain otalgia, and the ear or mastoid region may be red (erythematous). Fever or headaches may also be present. Infants usually show nonspecific symptoms, such as poor feeding, diarrhea, or irritability. Drainage from the ear occurs in more serious cases.

Diagnosis

The diagnosis of mastoiditis is clinical—based on the medical history and physical examination. Imaging studies may provide additional information; the study of choice is the CT scan, which may show focal destruction of the bone or signs of an abscess (a pocket of infection). X-rays are not as useful. If there is drainage, it is often sent for culture, although this will often be negative if the patient has begun taking antibiotics.

Pathophysiology

The pathophysiology of mastoiditis is straightforward: bacteria spread from the middle ear to the mastoid air cells, where the inflammation causes damage to the bony structures. The bacteria most commonly observed to cause mastoiditis are Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and gram-negative bacilli. Other bacteria include Moraxella catarrhalis, Streptococcus pyogenes, and rarely, Mycobacterium species. Some mastoiditis is caused by cholesteatoma, which is a sac of keratinizing squamous epithelium in the middle ear that usually results from repeated middle-ear infections. If left untreated, the cholesteatoma can erode into the mastoid process, producing mastoiditis, as well as other complications.

Treatment

The primary treatment for mastoiditis is administration of intravenous antibiotics. Initially, broad-spectrum antibiotics are given, such as ticarcillin/clavulanate (Timentin) plus gentamicin, or ciprofloxacin (Cipro). As culture results become available, treatment can be switched to more specific antibiotics. Long-term antibiotics may be necessary to completely eradicate the infection. If the condition does not quickly improve with antibiotics, surgical procedures may be performed (while continuing the medication). The most common procedure is a myringotomy, a small incision in the tympanic membrane (eardrum), or the insertion of a tympanostomy tube into the eardrum. These serve to drain the pus from the middle ear, helping to treat the infection. The tube is extruded spontaneously after a few weeks to months, and the incision heals naturally. If there are complications, or the mastoiditis does not respond to the above treatments, it may be necessary to perform a mastoidectomy in which a portion of the bone is removed and the infection drained.

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Brain abscess
From Gale Encyclopedia of Medicine, 4/6/01 by Richard Robinson

Definition

Brain abscess is a bacterial infection within the brain.

Description

The brain is usually well insulated from infection by bacteria, protected by the skull, the meninges (tissue layers surrounding the brain), the immune system, and the highly regulated barrier between the bloodstream and the brain. Under certain circumstances, however, bacteria can invade the brain and cause a localized infection called an abscess. Brain abscess is relatively rare, accounting for 1 in 10,000 hospital admissions. Single abscess occurs in 75% of cases, and the remainder of cases involve multiple abscesses. If not treated, brain abscess is almost always fatal.

Causes & symptoms

One-half of all brain abscesses are caused by the spread of bacteria from a nearby infection. Sources of bacteria include:

  • Middle ear infections (otitis media) or infections in the bony spaces in front of the middle ear (mastoiditis)
  • Sinus infections
  • An abscessed tooth.

Other sources of bacteria include:

  • Lung infections
  • Abdominal infection
  • Infection of the heart's lining (endocarditis)
  • Penetrating head wounds
  • Neurosurgery.

Acquired Immune Deficiency Syndrome (AIDS) or the presence of another immune deficiency greatly increases the risk of brain abscess. Approximately 25% of cases have no detectable cause of infection.

Brain abscess can be caused by a variety of organisms, many of them related to ear and sinus infections. Many times brain abscess cases are caused by two or more bacteria. In 30% to 60% of cases, the bacteria combination includes streptococci, microorganisms that can live without oxygen (anaerobes), and Enterobacteria. A small number of cases are caused by yeast, fungi, and single-cell organisms (protozoa).

The symptoms of brain abscess often develop slowly, usually within a period of about two weeks. The most common symptoms are:

  • Headache
  • Neurologic symptoms related to the specific part of the brain that is infected
  • Altered mental status
  • Seizures.

Fever and stiff neck occur in less than one-third of cases. Additional symptoms may include vomiting, eye tremor (nystagmus), poor balance, and uncoordinated movements.

Diagnosis

Diagnosis of brain abscess is performed by using a computed tomography scan (CT) or a magnetic resonance imaging (MRI) scan to determine the site of infection. Tissue removal (biopsy) is usually performed as well. A biopsy is performed to determine the type of bacterium involved. Biopsies can also be used to rule out tumor or other noninfectious localized lesions, which may look the same on the scans.

Other tests are performed to determine the source of the infection. These tests include blood cultures, x rays of the chest, and a physical exam of the ears, sinuses, and teeth. A test for human immunodeficiency virus (HIV) is usually also performed.

Treatment

Treatment for brain abscess begins with intravenous antibiotics, chosen to match the infecting bacterium if known, or to cover a wide spectrum of possibilities if not. Treatment usually continues for six to eight weeks.

Aspiration surgery is almost always done to drain the abscess. In this procedure, a needle is guided to the infected site by CT scan, and fluid is removed (aspirated) from the abscess. Aspiration may be repeated several times until the bacteria are completely killed or removed. Surgical removal of infected or dead tissue may be needed in some cases. For patients with many sites of infection, aspiration or surgical removal is not done because of the increased difficulty and risk of the procedure. For these patients, antibiotic therapy alone is used. Steroid treatment is controversial, but may be indicated in some cases.

Prognosis

Even with prompt treatment, brain abscess is fatal in about 20% of cases. About half of those who survive have some residual neurological problems, including seizures in many patients.

There are several reasons why patients with brain abscess can have a poor prognosis. The illness may not be diagnosed correctly or an accurate diagnosis may take additional time. The patient may receive an antibiotic that does not match the infecting organism. Sometimes the infection may not be limited to a definite area in the brain, making diagnosis and treatment difficult. The small number of cases caused by fungal infection may take additional time to diagnose. A patient may also have a poor prognosis because there is more than one abscess, the location of the abscess may be deep within the brain, or the infection may have moved into many locations within the brain. Severe complications can result from brain abscess, including comma and brain rupture. In 80-100% of cases involving brain rupture, the patient dies.

Prevention

Brain abscess may be preventable by prompt and aggressive treatment of the infections which give rise to it, especially sinus and ear infections.

Key Terms

Biopsy
The removal of a tissue sample for examination.
Aspiration
Removal of fluid from a closed space through a needle.

Further Reading

For Your Information

    Books

  • Fauci, Anthony editor. Harrison's Principles of Internal Medicine, 14th edition. McGraw-Hill, 1997.
  • Rolak, Loren A. "Brain and Spinal Abscesses." In Office Practice of Neurology, edited by Martin A. Samuels and Steven Feske. New York: Churchill Livingstone, 1996, pp.371-373.
  • Wispelwey, Brian and Carole A. Sable. "Intracranial Suppuration." In Current Therapy of Infectious Disease, edited by David Schlossberg. St. Louis, MO: Mosby-Year Book, 1996, pp.227-231.

Gale Encyclopedia of Medicine. Gale Research, 1999.

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