Examqo › Examqo library › Otolaryngology – Head and Neck Surgery › Otology and lateral skull base · IMLE
Complications of otitis media: mastoiditis and beyond
Middle ear infection can break into the mastoid bone, the inner ear, the facial nerve and the cranial cavity; the basic treatment is IV antibiotics with drainage of the middle ear (myringotomy ± tube), and mastoidectomy when there is an abscess, an intracranial complication or no improvement.
Why it matters in the exam
The exam shows a child with otitis and a red bulge behind the pinna pushing it forward and outward — acute mastoiditis — and asks about imaging and treatment. Contrast CT of the temporal bone shows breakdown of the mastoid septa (coalescent) or a subperiosteal abscess; MRI and MRV are needed when an intracranial complication is suspected. Masked mastoiditis is mastoiditis disguised by oral antibiotics: few symptoms but bone destruction on CT.
Complications are intratemporal or intracranial. Within the temporal bone: mastoiditis and subperiosteal abscess, Bezold abscess (an abscess beneath the sternocleidomastoid), petrositis with Gradenigo syndrome — ear discharge, retro-orbital pain (branch V1) and nerve VI palsy — labyrinthitis and facial nerve palsy. Facial palsy in acute otitis is treated with myringotomy, a tube, antibiotics and steroids, without surgery to open the nerve.
The commonest intracranial complication is meningitis. Others: epidural abscess, subdural empyema, brain abscess (temporal lobe or cerebellum), and thrombosis of the sigmoid (lateral) sinus — "picket-fence" fever, headache, Griesinger sign (oedema over the mastoid) and a filling defect on imaging (delta sign). Otitic hydrocephalus is raised intracranial pressure after sinus thrombosis. Treatment of the thrombosis: antibiotics, mastoidectomy, and anticoagulation considered case by case.
Key points
- Mastoiditis: contrast CT and IV antibiotics.
- Drain the middle ear in every complication.
- Mastoidectomy for abscess or no improvement in 48 hours.
- Gradenigo: discharge, eye pain, VI palsy.
- Sigmoid sinus thrombosis: Griesinger and delta sign.
Summary table
| Complication | Clue | Treatment |
|---|---|---|
| Acute mastoiditis | Red bulge behind the ear, pinna pushed outward | IV antibiotics, myringotomy ± tube; mastoidectomy for abscess or no improvement |
| Bezold abscess | Neck swelling beneath the sternocleidomastoid | Drainage and mastoidectomy |
| Gradenigo | Discharge, retro-orbital pain, nerve VI palsy | Prolonged antibiotics, drainage as needed |
| Facial nerve palsy | Facial weakness during acute otitis | Myringotomy, tube, antibiotics, steroids |
| Sigmoid sinus thrombosis | "Picket-fence" fever, Griesinger, delta sign | Antibiotics, mastoidectomy, consider anticoagulation |
| Brain abscess or meningitis | Headache, vomiting, altered consciousness | Urgent imaging, antibiotics, neurosurgery |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: ENT and head and neck surgery, Medical licensing exam (IMLE), Pediatrics, Emergency medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Complications of temporal bone infections
- AAP Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media, 2013 — Complications and referral
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Otitis media and its complications
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.