What is the treatment for acute mastoiditis?

Treatment of Acute Mastoiditis

Acute mastoiditis should be treated with intravenous antibiotics and myringotomy, with surgical intervention reserved for complicated cases or those failing to respond to initial medical management. 1

Definition and Diagnosis

Acute mastoiditis is the most common complication of acute otitis media (AOM), characterized by infection of the mastoid air cells. Clinical presentation typically includes:

• Post-auricular erythema, edema, and tenderness
• Protrusion of the auricle
• Fever
• Signs of concurrent acute otitis media

Treatment Algorithm

First-Line Treatment

1. Hospitalization for intravenous antibiotics

   • Cephalosporins are the antibiotics of choice due to prevalence of Streptococcus pneumoniae 2
   • Consider combination therapy when multibacterial flora is suspected

2. Myringotomy (surgical incision of the tympanic membrane)

   • Facilitates drainage of middle ear fluid
   • Allows for culture collection to guide antibiotic therapy
   • Should be performed early in the course of treatment 1, 3

Monitoring and Assessment

• Daily evaluation of clinical response
• Monitor for signs of improvement:
  • Reduction in post-auricular swelling
  • Decreased pain
  • Resolution of fever
  • Improvement in laboratory parameters (WBC, CRP)

Management of Uncomplicated Cases

• Continue intravenous antibiotics and observe
• According to evidence, 87% of patients with uncomplicated mastoiditis respond well to intravenous antibiotics and myringotomy alone 4

Management of Complicated or Non-Responsive Cases

Surgical intervention is indicated for:

1. Subperiosteal abscess formation
2. Intracranial complications
3. Failure to improve after 48 hours of appropriate antibiotic therapy
4. Clinical deterioration at any time 1

Surgical Options:

• Needle aspiration of subperiosteal abscess (may be sufficient in some cases) 1
• Simple mastoidectomy (removal of infected mastoid air cells)
• More extensive procedures for intracranial complications

Evidence-Based Approach

A review of 577 cases of acute mastoiditis from Sweden showed 1:

• 10% successfully treated with antibiotics alone
• 68% required antibiotics and myringotomy
• 22% required antibiotics and mastoidectomy

In another study, only 11.4% of patients required mastoidectomy or abscess drainage, while the majority (87%) responded to intravenous antibiotics and myringotomy 4.

Microbiology Considerations

Common pathogens include 2, 3:

• Streptococcus pneumoniae (most common)
• Streptococcus pyogenes
• Staphylococcus aureus
• Haemophilus influenzae
• Pseudomonas aeruginosa

Special Considerations

Outpatient Management

For select cases with periosteitis but without severe complications, outpatient parenteral antibiotic therapy may be considered after initial stabilization, using once-daily intramuscular ceftriaxone with close monitoring 5.

Complications to Monitor For

• Extracranial: Subperiosteal abscess, Bezold's abscess
• Intratemporal: Facial nerve palsy, labyrinthitis
• Intracranial: Meningitis, brain abscess, sinus thrombosis 2

CT Imaging

Consider CT scan if:

• No improvement after 48 hours of treatment
• Clinical deterioration at any time
• Suspicion of intracranial complications 1

Pitfalls to Avoid

1. Delaying treatment - Acute mastoiditis can progress rapidly to life-threatening complications
2. Relying solely on oral antibiotics - Intravenous therapy is essential initially
3. Omitting myringotomy - This procedure is crucial for drainage and obtaining cultures
4. Failing to recognize complications - Regular assessment for signs of intracranial or extracranial spread is essential
5. Premature discharge - Ensure clear clinical improvement before transitioning to oral therapy

Prior antibiotic treatment for AOM does not eliminate the risk of developing mastoiditis, as studies show 33-81% of mastoiditis patients had received antibiotics before admission 1.