What is the management approach for a patient suspected of having mastoiditis?

From the Guidelines

The management of suspected mastoiditis requires prompt medical attention with a combination of antibiotics, surgical intervention when necessary, and close monitoring, with an initial treatment involving broad-spectrum intravenous antibiotics that cover common pathogens including Streptococcus pneumoniae, as seen in the study by 1. The initial approach to managing mastoiditis involves the use of broad-spectrum intravenous antibiotics, such as ceftriaxone and vancomycin, to cover common pathogens including Streptococcus pneumoniae, as this bacterium remains the most common cause of acute mastoiditis (AM) across the globe, as noted in the study by 1. Key considerations in the management of mastoiditis include:

• The use of high-dose amoxicillin or amoxicillin-clavulanic acid as first-line antibiotics for acute otitis media (AOM), which can help reduce the risk of developing mastoiditis, as suggested by the guidelines outlined in 1.
• The importance of imaging studies, particularly CT scans of the temporal bone, to confirm the diagnosis and assess for complications, as part of a comprehensive approach to managing mastoiditis, as implied by the discussion on the role of CT scanning in the algorithm developed by Chesney et al, mentioned in 1.
• Surgical intervention, such as mastoidectomy, is indicated for patients who fail to respond to antibiotics within 24-48 hours, have abscess formation, or develop complications such as intracranial extension, highlighting the need for close monitoring and a multidisciplinary approach to care, as seen in the varying rates of mastoidectomy reported in different case series, ranging from 29% to 93% of patients with mastoiditis, as discussed in 1. 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, has been observed, with contemporary case series reporting varying rates of success with these approaches, as noted in 1. The management of mastoiditis should prioritize a combination of medical and surgical interventions, tailored to the individual patient's needs and response to treatment, with a focus on preventing complications and improving outcomes, as supported by the evidence presented in 1.

From the Research

Diagnostic Approach

• The diagnosis of mastoiditis can be made clinically, with signs and symptoms such as tympanic membrane erythema, pinna protrusion, postauricular erythema, mastoid tenderness, external canal swelling, otorrhea, fever, and malaise 2.
• Laboratory analysis may reveal evidence of systemic inflammation, but a normal white blood cell count and other inflammatory markers should not be used to exclude the diagnosis 2.
• Computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the clinician is unsure of the diagnosis, and may also demonstrate complications 2, 3.

Imaging Studies

• Imaging studies, such as CT scans and magnetic resonance imaging (MRI), should be reserved for children with suspected mastoiditis-related intracranial complications or those who do not improve with adequate medical therapy 3.
• A radiologist-derived systematic checklist, such as the 'mastoid 16', can be used to assist in interpreting cross-sectional imaging in emergency mastoiditis cases 4.

Treatment Approach

• Treatment of mastoiditis includes antibiotics, such as ampicillin-sulbactam or ceftriaxone, as well as otolaryngology consultation 2.
• Surgical intervention may be necessary for complications such as subperiosteal abscess, jugular vein thrombosis, perisinus empyema, epidural abscess, and Luc abscess 3, 5.
• The efficacy of treatment options for complications of acute mastoiditis can be evaluated by comparing the change in number of complication subtypes in each treatment subgroup (medical, conservative, or surgical) from admission to discharge or postdischarge follow-up 5.

Management of Complications

• Complications of mastoiditis, such as subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures, require prompt diagnosis and treatment 2, 5.
• Surgical patients had larger reductions in total number of complications, extracranial complications, and intratemporal complications at discharge and follow-up compared to medical and conservative patients 5.