Abstract

Acute mastoiditis (AM) is the most serious complication of acute otitis media (AOM). Variation persists in how clinical signs, radiologic imaging, and routine laboratory markers are used at first presentation. This study aimed to evaluate the diagnostic accuracy and clinical utility of bedside examination, computed tomography/ magnetic resonance imaging, and inflammatory markers for identifying AM and its complications. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Eligible observational studies and reviews enrolling children and/or adults with suspected AM and reporting accurate data or clinically anchored outcomes were included. Data were abstracted for predefined clinical signs, imaging features, laboratory values, and reference standards; heterogeneity precluded meta-analysis, and findings were synthesized narratively. Classic post-auricular features in the context of AOM (erythema/swelling, tenderness or fluctuance, and auricular proptosis) were the most reliable first-line indicators and were present in nearly all pediatric AM. Radiology reports of “mastoiditis” based on mastoid opacification alone showed poor positive predictive value; coalescent change (bony septal/cortical erosion) and sub-periosteal collections correlated best with clinically confirmed AM. MRI was highly sensitive for excluding intracranial extension but less specific for bony disease; CT remained the preferred test to confirm coalescence when red flags were present. Leukocytosis and elevated C-reactive protein were common and associated with severity, yet neither reliably confirmed nor excluded AM at presentation. Across cohorts, most uncomplicated pediatric cases were successfully diagnosed and managed without routine upfront imaging. Standardized, prospectively validated diagnostic pathways are needed to reduce overdiagnosis from inci dental mastoid opacification while safeguarding against missed complications.

Key words: Acute mastoiditis, clinical diagnosis, emergency setting, diagnostic accuracy, systematic review