What is the recommended treatment for mastoiditis?

Treatment of Mastoiditis

The recommended treatment for mastoiditis includes intravenous antibiotics as initial therapy, with surgical intervention reserved for cases that fail to respond to medical management within 48 hours or those with complications such as subperiosteal abscess or intracranial involvement. 1

Classification and Diagnosis

Mastoiditis is classified as:

• Uncomplicated mastoiditis: Clinical evidence of mastoid infection without bony erosion, coalescence, or abscess formation
• Complicated mastoiditis: Presence of subperiosteal abscess, intracranial complications, or evidence of bony erosion including coalescence 2

Key diagnostic criteria include:

• Otomicroscopic evidence of acute otitis media
• Displacement of the pinna
• Retroauricular swelling, erythema, and tenderness 3

Treatment Algorithm

1. Initial Medical Management (First-Line)

• Intravenous broad-spectrum antibiotics should be initiated immediately 1, 4

  • Recommended regimens:
    • Vancomycin plus piperacillin-tazobactam
    • Vancomycin plus a carbapenem (imipenem-cilastatin, meropenem, or ertapenem)
    • Vancomycin plus ceftriaxone and metronidazole 1

• Myringotomy (surgical incision of the tympanic membrane) should be considered to facilitate drainage 1, 5

• Duration: Initial IV therapy for 48-72 hours, then reassess 1, 4

2. Assessment After 48 Hours

• If improving: Continue IV antibiotics for total of 7-10 days, with potential transition to oral antibiotics after clinical improvement 1, 5

• If not improving or worsening: Proceed to imaging (CT scan) and consider surgical intervention 1, 4

3. Surgical Management (For Specific Indications)

Surgical intervention is indicated for:

• Failure to respond to 48 hours of appropriate IV antibiotics
• Presence of subperiosteal abscess
• Evidence of bony erosion or coalescence
• Intracranial complications 1, 2

Surgical options include:

• Mastoidectomy: Removal of infected mastoid air cells
• Incision and drainage: For subperiosteal abscess 1

Special Considerations

Uncomplicated vs. Complicated Mastoiditis

• Truly uncomplicated mastoiditis (no bony erosion or abscess) can often be managed with antibiotics alone and may not require mastoidectomy 2

• Complicated mastoiditis almost always requires surgical intervention in addition to antibiotics 1, 4

Outpatient Management

• Select patients with uncomplicated mastoiditis may be managed as outpatients with daily follow-up and parenteral antibiotics (e.g., once-daily IM ceftriaxone) 3

• Requirements for outpatient management:

  • Reliable follow-up
  • No signs of systemic toxicity
  • No evidence of complications
  • Daily assessment by specialists 3

Monitoring and Follow-up

• Daily clinical assessment during acute phase
• Repeat imaging for persistent fever or bacteremia to identify undrained foci of infection 1
• Follow-up audiometry to assess for hearing loss after resolution

Potential Pitfalls

1. Delayed surgical intervention: Waiting too long for surgical intervention in complicated cases can lead to increased morbidity and risk of intracranial complications

2. Inadequate antibiotic coverage: Failure to cover both aerobic and anaerobic organisms can result in treatment failure

3. Incomplete drainage: Inadequate drainage of purulent material can lead to persistent infection 1

4. Missing intracranial complications: Brain abscess is the most common intracranial complication of otitis media, with an estimated incidence of 1 per million per annum 1

The treatment approach to mastoiditis has evolved from primarily surgical to a more balanced approach with emphasis on early medical management, reserving surgery for specific indications. This approach has been shown to be effective in reducing morbidity while maintaining excellent outcomes 5.