From the Guidelines
Mastoiditis is a serious bacterial infection of the mastoid bone behind the ear, typically developing as a complication of untreated middle ear infections, and requires prompt medical attention with hospitalization for intravenous antibiotics and possible surgical intervention. Symptoms of mastoiditis include severe ear pain, swelling and redness behind the ear, ear drainage, fever, headache, and hearing loss. The affected area may protrude outward, and the ear might appear to stick out. Treatment typically involves hospitalization for intravenous antibiotics such as ceftriaxone (1-2g IV every 12-24 hours) or ampicillin-sulbactam (3g IV every 6 hours) for 7-10 days, as suggested by recent studies 1. Surgical intervention is often necessary, including myringotomy (eardrum incision) to drain fluid or a more extensive mastoidectomy to remove infected bone tissue, with mastoidectomy rates between 29% and 93% of patients with mastoiditis 1. After hospital treatment, patients usually continue oral antibiotics like amoxicillin-clavulanate (875/125mg twice daily) for 1-2 weeks. Pain management with acetaminophen or ibuprofen is also important. Mastoiditis requires aggressive treatment because the infection can spread to surrounding structures, potentially causing serious complications like meningitis, brain abscess, or facial nerve paralysis if left untreated, as highlighted in a study from Sweden where 10% of patients were successfully treated with antibiotics alone, 68% with antibiotics and myringotomy, and 22% with antibiotics and mastoidectomy 1. Children are particularly susceptible to mastoiditis, and any signs of ear infection that worsen or don't improve with treatment should prompt immediate medical evaluation. Some studies suggest that needle aspiration can be performed for confirmation of diagnosis, but the subperiosteal abscess will often recur with needle aspiration alone 1. The decision to treat mastoiditis should be based on the most recent and highest quality evidence, prioritizing morbidity, mortality, and quality of life as the outcome, as seen in a recent trend toward nonsurgical management with intravenous antibiotics, either alone or combined with myringotomy and TT insertion and/or needle aspiration of the subperiosteal abscess 1. Key factors in the diagnosis and management of mastoiditis include the use of pneumatic otoscopy and tympanometry, and the treatment of pain, as outlined in national guidelines for AOM 1. The use of antibiotics in the treatment of mastoiditis is crucial, with high-dose amoxicillin or amoxicillin-clavulanic acid being commonly used, and the potential for reducing antibiotic use in select cases of AOM, as suggested by studies from the Netherlands and Sweden 1. However, the risk of mastoiditis after AOM is still present, even with antibiotic treatment, and the high NNT of approximately 4800 patients to prevent 1 case of mastoiditis precludes a strategy of universal antibiotic therapy as a means to prevent mastoiditis 1. In conclusion, mastoiditis is a serious infection that requires prompt medical attention and aggressive treatment to prevent serious complications and improve quality of life.
Symptoms of Mastoiditis
- Severe ear pain
- Swelling and redness behind the ear
- Ear drainage
- Fever
- Headache
- Hearing loss
Treatment Options for Mastoiditis
- Hospitalization for intravenous antibiotics
- Surgical intervention, including myringotomy or mastoidectomy
- Oral antibiotics after hospital treatment
- Pain management with acetaminophen or ibuprofen
Important Considerations in the Diagnosis and Management of Mastoiditis
- Use of pneumatic otoscopy and tympanometry
- Treatment of pain
- Potential for reducing antibiotic use in select cases of AOM
- Risk of mastoiditis after AOM, even with antibiotic treatment
- High NNT of approximately 4800 patients to prevent 1 case of mastoiditis precludes a strategy of universal antibiotic therapy as a means to prevent mastoiditis 1
From the Research
Symptoms of Mastoiditis
- Tympanic membrane erythema
- Pinna protrusion
- Postauricular erythema
- Mastoid tenderness with palpation
- External canal swelling
- Otorrhea
- Fever
- Malaise 2
Treatment Options for Mastoiditis
- Antibiotics such as ampicillin-sulbactam or ceftriaxone
- Otolaryngology consultation 2
- Surgical management, including complete mastoidectomy and pressure equalization tube placement 3
- Adjunct treatment, such as anticoagulation for sigmoid sinus thrombosis 4
- Medical, conservative, or surgical treatment, with surgical treatment showing larger reductions in complications 5