[Development of the sigmoid sinus and pneumatization of the mastoid process. With a contribution to the problem of secondary sclerosing of the mastoid process].
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Colon, Sigmoid↗
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High incidence and spontaneous resolution of mastoid effusion after craniotomy on early postoperative magnetic resonance images.
Mastoid effusion is a poorly understood complication after craniotomy. The incidence and severity of postoperative mastoid effusion were retrospectively examined on postoperative magnetic resonance (MR) images to assess any association with craniotomy procedures, time course, and neuro-otological complications. We evaluated the early postoperative MR images (within 4 days of craniotomy) and medical records of 74 patients who underwent 77 operations for the treatment of various intracranial diseases from January 2000 to December 2001. Mastoid effusion was classified into four grades: none, partial, moderate, and severe diffuse effusion in the mastoid air cells. Thirty-three follow-up MR images from 26 patients were also reviewed. Postoperative mastoid effusion occurred ipsilateral to the craniotomy site in 62 cases and contralateral in 56 cases. Mastoid effusion was significantly more severe ipsilateral than contralateral to craniotomy with exposure of the mastoid air cells ( P<0.0001). There was no significant difference in severity between the contralateral and ipsilateral sides after craniotomy without mastoid air cell opening ( P=0.437). Mastoid effusion following craniotomy without exposure of mastoid air cells resolved within 3 months. However, otitis media with effusion developed in six patients with severe mastoid effusion ipsilateral to craniotomy with exposure of the mastoid air cells. Mastoid effusion frequently developed on both sides. Any grade of mastoid effusion on the ipsilateral side to craniotomy without exposure of mastoid air cells, or on the contralateral side, was asymptomatic or had a benign course, and disappeared within 3 months.
Brain Neoplasms↗
Efficacy of mastoid cortex plasty for middle ear aeration in intact canal wall tympanoplasty for cholesteatoma.
OBJECTIVE: To determine the effect of closing the bone defect of the mastoid cortex using bone pate after mastoidectomy (mastoid cortex plasty) during the first-stage operation for the restoration of the mastoid cavity aeration. STUDY DESIGN: This was a prospective study. SETTING: Tertiary medical center. PATIENTS: Thirty-five patients with cholesteatoma invading the mastoid cavity. INTERVENTION: Seventeen patients received mastoid cortex plasty with scutum plasty and insertion of a Silastic sheet after removal of the cholesteatoma using a combined approach during the first-stage operation. The 18 control patients received only scutum plasty with the insertion of a Silastic sheet without mastoid cortex plasty during the first-stage operation. MAIN OUTCOME MEASURES: The restoration of the middle ear aeration was assessed with high-resolution computed tomography before both the first-stage operation and the second-stage operation. RESULTS: The range of middle ear aeration ameliorated significantly whether or not mastoid cortex plasty was performed. Scutum plasty with the insertion of a Silastic sheet without mastoid cortex plasty was significantly effective only for the amelioration of the epitympanum aeration. Mastoid cortex plasty with scutum plasty with the insertion of a Silastic sheet was significantly effective for the amelioration of the epitympanum and also the mastoid cavity aeration. In both groups, before the first-stage operation, approximately 70% of the patients had good mesotympanum aeration, and the mesotympanum aeration ameliorated further after the first-stage operation, although this amelioration was not significant. CONCLUSIONS: Mastoid cortex plasty is statistically effective for the amelioration of mastoid cavity aeration after the first-stage operation.
Adolescent↗
Mastoid cortex plasty using bone pate.
OBJECTIVE: To describe the surgical technique of mastoid cortex plasty using bone pate and its clinical significance. STUDY DESIGN: Retrospective. SETTING: Tertiary medical center. METHODS: Bone pate collected while drilling the mastoid cortex was mixed with fibrin glue to make a pate plate. The mastoid cortex defect was closed with a pate plate cut to the desired shape and size. PATIENTS AND MAIN OUTCOME MEASURES: Mastoid cortex plasty was included in the first-stage operation in 49 patients who underwent staged tympanoplasty. The second-stage operation was an inspection to see whether the mastoid cortex was reconstructed and the ingrowth of fibrous soft tissue was prevented. RESULTS: In 35 patients, the mastoid cortex was reconstructed completely, and soft tissue ingrowth into the mastoid cavity was blocked completely. In the remaining 14 patients, a defect of varying size occurred at the site of drainage-tube insertion. This defect was small enough to prevent soft tissue ingrowth into the mastoid cavity. CONCLUSION: Mastoid cortex plasty is a simple and rapid procedure for preventing postoperative deformity of the mastoid process and is valuable for restoring mastoid cavity function.
Adolescent↗
Acute mastoiditis in Southern Israel: a twelve year retrospective study (1990 through 2001).
BACKGROUND: Acute mastoiditis is a serious complication of acute otitis media (AOM) and has been increasingly reported in the last decade. OBJECTIVES: To report the experience accumulated with acute mastoiditis at the Soroka University Medical Center, Beer-Sheva, Israel, in a period of increasing antimicrobial resistance with Streptococcus pneumoniae. PATIENTS AND METHODS: We reviewed the records of all children with acute mastoiditis hospitalized from 1990 through 2001. Acute mastoiditis was diagnosed when one or more of the physical signs of mastoiditis (swelling, erythema, tenderness of the retroauricular area and anteroinferior displacement of the auricle) were diagnosed in the presence of concomitant or recent (< or =4 weeks) AOM. RESULTS: One hundred sixteen episodes of acute mastoiditis occurred in 101 children age 2 months to 14 years (median, 25 months; 19% <1 year old). The average yearly incidence was 6.1 cases per 100 000 population <14 years old, with a significant increase in the number of cases during the study period. Acute mastoiditis was the first evidence of AOM in 10 (10%) patients. Fever >38 degrees C and >15,000 WBC/mm3 were present in 67 and 43% of cases, respectively. Irritability, retroauricular swelling, redness and protrusion of the auricle occurred more commonly in patients <3 years old (79, 90, 84 and 76% vs. 28, 42, 45 and 30%, respectively, in patients > or =3 years old; P < 0.002). Computed tomography scans were performed in 54 of 116 (47%) cases and revealed bone destruction in 38 (70%). Periosteal abscess and lateral sinus vein thrombosis were diagnosed in 8 and 2 patients, respectively. Simple mastoidectomy was done in 32 of 116 (28%) cases, after no response to intravenous antibiotics was observed; ventilation tubes were inserted in 12 patients. Cultures were obtained at admission in 83 (72%) episodes (71 by tympanocentesis and 12 from ear discharges). Overall 43 pathogens were isolated: 34 at admission; 14 at surgery; and 5 at both occasions. The most commonly isolated organisms were S. pneumoniae (14 of 43, 33%; 4 penicillin-nonsusceptible), Streptococcus pyogenes (11 of 43, 26%), nontypable Haemophilus influenzae (6 of 43, 14%), Pseudomonas aeruginosa (5 of 43, 12%) and Escherichia coli (4 of 43, 9%). All S. pneumoniae organisms were isolated between 1996 and 2001. CONCLUSIONS: (1) The incidence of acute mastoiditis in children in Southern Israel is greater than that reported in the literature; (2) a significant increase in the number of cases was recorded during the study period; (3) the clinical picture of acute mastoiditis was more severe in infants and young children; (4) the pathogen distribution in acute mastoiditis differs from that of AOM with significantly higher rates of S. pyogenes and lower rates of nontypable H. influenzae recovery; (5) penicillin-nonsusceptible S. pneumoniae played only a minor role in the etiology of acute mastoiditis in Southern Israel.
Acute Disease↗
[Temporal bone study of residual mastoid inflammation in ears with normally appearing tympanic membrane].
We examined 395 temporal bones with an intact tympanic membrane to explore the relationship between residual inflammation in the middle ear cavity and development of mastoid pneumatization. Histopathological changes were studied in the middle ear cavity. Mastoid pneumatization was classified as good or poor based on the extent of mastoid tip development to the lateral semicircular canal. Specimens were 344 temporal bones with well-pneumatized mastoid and 51 with poorly-pneumatized mastoid. Otitis media was noted in 119 (34.6%) bones in the good group and 9 (17.6%) in the poor group. In well-pneumatized mastoid, chronic inflammatory changes were frequently observed at the lower portion of mastoid cells, the round window niche, and the tympanic sinus. In contrast, no such incidence of inflammatory change was noted in poorly-pneumatized mastoid. Our findings indicate that an intact tympanic membrane does not always mean freedom from mastoid inflammation, especially when the mastoid is well-pneumatized. This makes it important to check for possible remaining otitis media in patients with a well-pneumatized mastoid, even if the tympanic membrane appears normal.
Ear, Middle↗
Mastoiditis in Kelantan.
Chronic mastoiditis and subperiosteal abscess are rarely seen nowadays in most countries. Thirty-four cases of mastoiditis were reviewed to find out the prevalence of chronic mastoiditis in the east coast of Malaysia. Twenty (58.82%) of these cases were a sequelae of chronic suppurative otitis media with cholesteatoma. All the patients with chronic mastoiditis were more than six years old. Forty-five percent of cases with chronic mastoiditis had a well pneumatized mastoid air cell on the unaffected side. The occurrence of chronic mastoiditis or cholesteatoma in a well pneumatized mastoid is not really as rare as was thought to be. X-ray of the mastoids is very useful in diagnosing patients with chronic mastoiditis and cholesteatoma. Mastoiditis is uncommon in adults and whenever a case is seen, an underlying pathology like cholesteatoma should be suspected.
Adolescent↗
Acute mastoiditis and osteomyelitis of the temporal bone.
OBJECTIVE: Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone. PATIENTS AND METHODS: The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment. RESULTS: The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications. CONCLUSION: The present study describes an unusual complication of acute mastoiditis-osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.
Acute Disease↗
Evaluation of mastoid air cell system by three-dimensional reconstruction using sagittal tomography of the temporal bone.
The mastoid air cell system has been recognized as an important contributor to the pathophysiology of middle ear inflammatory diseases. Various methods of temporal bone imaging have been designed to investigate the correlation between middle ear disease and mastoid pneumatization. In this study, the mastoid air cell system was reconstructed three-dimensionally from sagittal tomographic images of the temporal bone on X-ray films, using a personal computer to evaluate the mastoid pneumatization in a total of 29 patients with chronic otitis media, adhesive otitis media, adhesive-type cholesteatoma, attic cholesteatoma and cholesterol granuloma, and in five normal subjects as controls. Reconstructed three-dimensional images of the mastoid air cell system and its volume were analyzed. The reconstructed images were helpful in recognizing the three-dimensional solid appearance of the mastoid air cell system. The volume of the reconstructed mastoid air cell system was significantly reduced compared with that in the controls in each of the patient groups. Mastoid pneumatization in the patients with adhesive-type cholesteatoma was significantly suppressed compared with that in the adhesive otitis media patients. Interestingly, the adhesive otitis media group showed cell development at the tip of mastoid process, whereas the group of adhesive-type cholesteatoma did not, suggesting a difference in the pathophysiology in the two diseases. We found that three-dimensional reconstruction of the temporal bone using sagittal tomographic images was useful in evaluating the state of mastoid air cell system development in individual cases and in investigating the pathophysiology in middle ear disease.
Adolescent↗
Gas exchange function through the mastoid mucosa in ears after surgery.
Gas exchange function through the mastoid mucosa was investigated in ears after surgery using nitrous oxide. Increase in the mastoid pressure was assessed by a micropressure sensor placed in the mastoid cavity during the second-stage revision operation performed under general anesthesia using 67% nitrous oxide, 33% oxygen, and sevoflurane on 14 ears with chronic adhesive otitis media or cholesteatoma as well as on seven ears without inflammation as controls. All seven control ears showed pressure increase in the mastoid in various degrees. In the 14 postoperative ears, nine of the 10 ears on which the mastoid mucosa had previously been able to be preserved in various degrees showed pressure increase in the mastoid, but none of the remaining four ears, which had previously had mastoidectomy, showed any pressure increase. The presence or absence of the mastoid pressure increase of those ears was also found to be correlated well with the presence or absence of mastoid aeration on computed tomography examined just before the second-stage operation. These results appear to indicate that, in ears after surgery, recovery of both the gas exchange function and aeration in the mastoid is expected only when the mastoid mucosa can be preserved even partially.
Adolescent↗
Mastoid and tympanic membrane as pressure buffers: a quantitative study in a middle ear cleft model.
HYPOTHESIS: The tympanic membrane (TM) and mastoid air cells are measurable pressure buffers of the middle ear (ME). BACKGROUND: Pressure homeostasis of the ME is maintained approximately atmospheric by mechanisms that neutralize (buffer) pressure fluctuations, two of which are the TM and mastoid. MATERIALS AND METHOD: Negative pressures were induced by volume changes in an artificial ME model. Those were recorded directly while using a rigid or a flexible TM with "mastoids" of various sizes. RESULTS: In the rigid TM model, the volume changes correlated linearly with the induced pressures and were confirmed to fit Boyle's law. In the flexible TM model, the pressure/volume correlation was nonlinear up to -50 mmH2O, where the TM was maximally displaced (approximately 25 mm3), became rigid, and constituted 75%, 41%, and 33% of the buffering gained in tandem with the "mastoid" in a model having a "mastoid" of 0, 5, and 10 mL, respectively. Altogether, a large "mastoid" required a greater volume change than a small one to induce the same pressure. CONCLUSIONS: The mastoid air volume "dilutes" pressure changes relatively to its size: the volume change required to alter a given pressure in an average (6 mL) mastoid is six-fold that which is needed in a small (1 mL) mastoid. ME volume reduction by TM retraction buffer negative ME pressures. This maximal ME volume change is constant for a "normal" TM. Therefore, it is the ME with the small mastoid that is most vulnerable to pressure changes and may develop compensatory buffering mechanisms, e.g., additional TM retraction (atelectasis) and/or ME volume reduction by fluid accumulation.
Acoustic Impedance Tests↗
Regeneration of mastoid air cells in clinical applications by in situ tissue engineering.
OBJECTIVES: To regenerate of the mastoid air cells and their functions for the treatment of incurable otitis media. MATERIALS AND METHOD: In situ tissue-engineered mastoid air cells using three-dimensional hydroxy apatite (3D-HA) of honeycomb-like structure were used as artificial pneumatic bones. This 3D-HA is made of calcium phosphate and has a high ratio of micropores, 90%. Its surface is coated with collagen. Ten patients (4 males, 6 females) for this clinical study were randomly selected among the patients with severe cholesteatoma, adhesive otitis media, and purulent chronic otitis media, and they were to be received a staged operation. At the first stage of tympanoplasty, collagen-coated 3D-HA was put into the newly opened mastoid cavity, and it was fixed by fibrin glue. Recovery of mastoid aeration and regeneration of the pneumatic air cells of the mastoid cavity were estimated by images of high-resolution computed tomography (HRCT) after the first operation. At the second stage of operation, histopathologic examinations of specimens of HA taken from the reopened mastoid cavity were performed. RESULTS: Aerations in the mastoid cavity were observed in 9 of the 10 patients within 12 months after the second operation. Moreover, the pneumatic structure in the mastoid cavity was partially regenerated in five patients. In these successful cases, mucosa with newly formed capillaries was observed on the surface of the implanted HA at the second stage of operation. In the failure cases, however, connective tissues and granulations invaded the space of the 3D-HA. They were observed as soft-tissue density areas in the HRCT scan images. CONCLUSIONS: This study indicates that mucosa can grow on the surface of implanted artificial 3D-HA and can have a gas exchange function in the newly opened mastoid cavity. These tissue-engineered mastoid air cells may be a possible treatment for intractable otitis media.
Adult↗
Role of the mastoid in tympanic membrane reconstruction.
Otologists have long debated the importance of the mastoid in determining the success or failure of tympanic membrane reconstruction. The pneumatic spaces within the mastoid represent an "air reservoir" which can be drawn upon during periods of eustachian tube dysfunction and buffer the middle ear against the development of detrimental negative pressures. Mastoid inflammatory disease, if untreated, may result in recurrent suppuration and graft failure. Small mastoid volume, aside from its well known association with chronic infectious middle ear disease, has been shown to effect adversely graft survival following myringoplasty. In 48 patients undergoing myringoplasty with simple mastoidectomy, neither small mastoid size nor inflammatory mastoid disease significantly decreased the rate of graft healing. This suggests that simple mastoidectomy is an effective means of repneumatizing the mastoid and eradicating mastoid sources of infection. The successful surgical creation of a pneumatized mastoid cavity in communication with the middle ear was confirmed by postoperative computerized tomographic (CT) scans. In failed cases, CT scanning predictably identified residual mastoid disease. Simple mastoidectomy is considered to be a safe and useful adjunct to myringoplasty in selected cases of chronic otitis media with perforation.
Hearing↗
[Pneumatization of the mastoid process in medieval and contemporary skulls in light of radiologic and anthropometric measurements].
Pneumatization and morphogenesis of the temporal mastoid process take place concurrently and exhibit noticeable variability. The mastoid process is phylogenetically the youngest part of the skull. The aim of this work was to examine the pneumatization of the mastoid process in mediaeval and contemporary skulls using radiological and anthropometric methods. 85 male skulls from the second half of the 20th century were compared with 102 male and 50 female skulls from the Middle Ages. Bilateral X-ray images of mastoid processes according to Schuller were obtained and anthropometric measurements were done. Planimetry was used to obtain the air cell area of the mastoid processes. Correlations between several parameters of the temporal bone, facial bones, cranial bones and pneumatization of the mastoid process were studied. X-ray images revealed four types of the mastoid process: pneumatic, mixed, sclerotic, and apneumatic. The pneumatic mastoid process prevailed in every group of skulls. The mixed type was the least frequent in mediaeval female skulls and most frequent in contemporary male skulls. The apneumatic type was the rarest one in all groups of skulls. The largest surface area of mastoid air cell system was found in contemporary male and the smallest in mediaeval female skulls (Fig. 5). An asymmetry between left and right processes was observed in mediaeval and contemporary skulls, being more evident in the latter. No correlation was found between anthropometric parameters of the skull and the extent of pneumatization of the mastoid process.
Adult↗
Sensitivity and specificity of mastoid vibration test in detection of effects of vestibular neuritis.
Aim of this study was to determine sensitivity and specificity of the mastoid vibration test in patients who had suffered an attack of vestibular neuritis. Results were compared with the caloric test and two bedside tests of vestibular function (head shaking test and head thrust test). Results are reported in 28 patients who had a residual vestibular deficit 6 months after acute neuritis and in 25 healthy subjects. Mastoid vibration nystagmus was evoked in 21 patients but not in controls. In these patients, mastoid vibration test had a sensitivity of 75% and specificity of 100%. Since one patient had inverted mastoid vibration nystagmus, specificity of identification on the pathological side was 95%. Sensitivity of the test increased with increasing severity of the vestibular lesion. Indeed, mastoid vibration nystagmus was induced in 93% of patients with caloric paralysis and in 58% of those with caloric paresis. Nystagmus could usually be modulated or elicited by stimulation of either mastoid. In the few patients in whom mastoid vibration nystagmus was elicited only from one side, or when there was a clear difference in intensity of the nystagmus induced on the two sides, the stimulated side was more often the affected side. Four patients still showed spontaneous nystagmus. The caloric test was abnormal in 26/28 patients (93%) with paralysis in 16 and paresis in 12; 71% of patients had a head shaking induced nystagmus: 64% had an asymmetrical response in head thrust test. In conclusion, mastoid vibration test was overall more sensitive than head thrust test. Mastoid vibration test was slightly less sensitive than head shaking test in patients with severe residual deficit and more sensitive in patients with partial deficit. Mastoid vibration test, a valid, low cost clinical screening test for rapid detection of asymmetrical vestibular function, does not cause patient discomfort. It is suggested that this test be included in the diagnostic workup of all patients with suspected vestibular dysfunction.
Acute Disease↗
Middle ear pressure variations during 50% N2O anesthesia as a function of mastoid pneumatization.
HYPOTHESIS: Mastoid size is a factor in middle ear (ME) pressure regulation. BACKGROUND: In a study investigating ME pressure variations during nitrous oxide (N2O) anesthesia, particularly high values of ME pressure increase rate (PIR) were observed in four patients with sclerotic mastoids. The current study is aimed at systematically assessing this observation. METHODS: Middle ear pressure was measured periodically in 30 patients during 50% N2O anesthesia using tympanometry. For each patient, a curve representing ME pressure during anesthesia was plotted. From the curve steepness, the PIR was calculated. Extent of mastoid pneumatization was assessed planimetrically using mastoid x-rays. Ears then were divided by the median into two groups: ears with small mastoids and ears with large mastoids. The difference between the mean PIR of both ear groups was statistically analyzed. RESULTS: A significant difference between the PIR was found among the two groups. In ears with mastoids smaller than 9.475 cm2 (the median), the PIR was significantly higher than in ears with mastoids > 9.475 cm2. CONCLUSIONS: These findings support the concept that the mastoid has a ME pressure buffering capability: the larger its volume, the better its buffering capability. It is therefore suggested, that the mastoid plays a role in ME pressure regulation.
Acoustic Impedance Tests↗
Mastoid air sinus abnormalities associated with lateral venous sinus thrombosis: cause or consequence?
BACKGROUND: Mastoiditis is a known cause of lateral venous sinus thrombosis (LST). We have encountered patients with LST associated with mastoid abnormality on MRI without any clinical signs of infection; the significance of these abnormalities is uncertain. This study examines the relationship of LST and mastoid air sinus abnormalities systematically. SUMMARY OF REPORT: We performed a retrospective clinical and radiological review of a series of 26 patients with cerebral venous thrombosis. Mastoid abnormalities were detected ipsilateral to 9 of 23 thrombosed lateral sinuses (39%) and 0 of 29 unaffected lateral sinuses (P<0.001). No patient had clinical evidence of mastoiditis. Eight of 9 patients with mastoid abnormalities were treated without antibiotics; all made uneventful clinical recoveries. Repeated MRI in 1 patient revealed reversal of the mastoid changes. CONCLUSIONS: The mastoid changes observed are likely to be due to venous congestion as a consequence of LST, not mastoiditis.
Adolescent↗
Assessment of mastoid air cell size versus sigmoid sinus variables with a tomography-assisted digital image processing program and morphometry.
We assessed the mastoid air cell size and variables of the sigmoid sinus in healthy ears and ears with chronic otitis media (COM). Thirty-eight patients with unilateral COM [15 with cholesteatoma (COM/+) and 23 without cholesteatoma (COM/-)], and 20 subjects with healthy ears, were included in the study. Assessment was performed using a quantitative digital image processing computed tomography (CT) program, and the volume of the mastoid bone was measured using the morphometric method of Cavalieri. In both COM/+ and COM/- patients the sigmoid to suprameatal spine distance and mastoid size were greater on the healthy side than on the diseased side ( p<0.05). The distance and area were significantly greater in the healthy control subjects than in either the healthy or the diseased ears of the patients with COM ( p<0.05). In the healthy ears of COM patients, there was significant correlation between the sigmoid to suprameatal spine distance and air cell size and mastoid volume ( p<0.05). In the diseased ears of COM patients, this correlation was absent ( p>0.05). The sigmoid sinus shape was of the half-moon type (62%), protrusive type (22%) and saucer type (16%). The digital image processing CT program allowed us to estimate the individual area of the air and soft tissue filled mastoid air cells. The mastoid size in both intact and disease ears of COM patients was smaller than in the healthy controls. The mastoid size may be determined genetically. However, environmental factors such as infection may also affect the mastoid size. Therefore, both genetic and environmental factors may be related to COM as far as the size of the mastoid air cells is concerned.
Adult↗