What are the symptoms and treatment options for mastoiditis?

Mastoiditis Symptoms and Treatment

Mastoiditis presents with postauricular swelling, erythema, tenderness, protrusion of the auricle, fever, and signs of concurrent or recent otitis media, requiring prompt treatment with intravenous antibiotics as first-line therapy, with surgical intervention reserved for cases that fail to respond to medical management or present with complications. 1

Clinical Presentation of Mastoiditis

Key Symptoms and Signs

• Postauricular swelling, erythema, or tenderness
• Protrusion of the auricle
• Fever
• Tympanic membrane erythema
• External ear canal swelling
• Otorrhea (ear drainage)
• Malaise 2
• Mastoid tenderness with palpation 2
• Otalgia (ear pain)
• Headache 1

Atypical Presentations

• Adults may present with latent forms that have prolonged, insidious development followed by rapid clinical deterioration 3
• Symptoms may be less pronounced in patients who have received prior antibiotic therapy 1

Complications of Mastoiditis

Extracranial Complications

• Subperiosteal abscess (most common extracranial complication) 4
• Bezold's abscess (extension into the neck) 5

Intratemporal Complications

• Facial nerve palsy 5
• Labyrinthitis 5

Intracranial Complications

• Meningitis
• Brain abscess
• Sigmoid sinus thrombosis
• Perisinus abscess
• Subdural abscess 4, 5

Diagnostic Approach

Clinical Evaluation

• Look for signs of otitis media with mastoid involvement
• Assess for pinna protrusion and postauricular swelling/redness
• Evaluate for systemic symptoms (fever, malaise)

Laboratory Tests

• Complete blood count (elevated white blood cells)
• C-reactive protein (elevated)
• Note: Normal inflammatory markers should not exclude the diagnosis 2

Imaging

• Computed tomography (CT) of temporal bones with intravenous contrast is the recommended imaging modality 2
• MRI may be necessary for evaluating intracranial complications 1
• Failure to obtain appropriate imaging when clinical improvement doesn't occur within 48 hours may miss developing complications 1

Treatment Algorithm

1. Initial Management

• Hospitalization for intravenous antibiotics 1
• First-line antibiotic options:
  • Vancomycin plus piperacillin-tazobactam
  • Vancomycin plus a carbapenem
  • Vancomycin plus ceftriaxone and metronidazole 1
  • Alternative: ampicillin-sulbactam or ceftriaxone 2

2. Adjunctive Procedures

• Myringotomy (surgical incision of the tympanic membrane) to facilitate drainage 1
• Immediate otolaryngology consultation 2

3. Monitoring Response

• Assess clinical improvement within 48 hours of starting IV antibiotics
• If improving: continue medical management
• If not improving: consider surgical intervention 1

4. Surgical Intervention Indications

• Subperiosteal abscess
• Bony erosion/coalescence
• Failure to respond to 48 hours of IV antibiotics
• Intracranial complications 1

5. Surgical Options

• Mastoidectomy (complete or canal wall down depending on severity)
• Drainage of subperiosteal abscess when present 1, 4

6. Treatment Duration

• Total antibiotic therapy: 2-3 weeks
• Transition to oral antibiotics once clinically improved with no evidence of bacteremia 1

Important Clinical Pearls and Pitfalls

Pearls

• About two-thirds of uncomplicated cases may recover with conservative therapy (myringotomy and IV antibiotics) 6
• Early diagnosis and treatment are crucial to prevent serious complications 2

Pitfalls

• Prior antibiotic treatment does not reliably prevent mastoiditis; studies show 33-81% of patients diagnosed with acute mastoiditis had received antibiotics prior to admission 1
• Relying solely on clinical improvement without appropriate imaging may miss developing complications 1
• Delayed surgical intervention can lead to serious intracranial complications 1
• Clinical features in adults are frequently atypical, while incidence of meningitis and other complications is high, particularly in the elderly 3