What is the treatment for mastoiditis?

Treatment of Mastoiditis

The treatment of mastoiditis requires intravenous antibiotics as first-line therapy, with surgical intervention reserved for cases that fail to respond to medical management or present with complications. 1

Classification and Initial Management

Mastoiditis treatment depends on accurate classification:

1. Uncomplicated Mastoiditis:

   • First-line treatment: Intravenous antibiotics
   • Specific antibiotic regimen: Cloxacillin/flucloxacillin IV 50 mg/kg QDS for 10 days 2
   • Alternative (second-line): Ceftriaxone IV 2

2. Complicated Mastoiditis (presence of subperiosteal abscess, bony erosion/coalescence, or intracranial complications):

   • Requires both IV antibiotics and surgical intervention
   • Broader antibiotic coverage may be needed: vancomycin plus piperacillin-tazobactam, vancomycin plus a carbapenem, or vancomycin plus ceftriaxone and metronidazole 1

Medical Management Protocol

• Begin IV antibiotics immediately upon diagnosis
• Perform myringotomy to facilitate drainage in most cases 1
• Assess response to treatment within 48 hours
• Continue IV antibiotics for 7-10 days if improvement occurs 1
• Total antibiotic duration: 2-3 weeks (transition to oral antibiotics once clinically improved) 1

Surgical Intervention Indications

Surgical management (including mastoidectomy) is indicated when:

• Subperiosteal abscess is present
• Bony erosion or coalescence is evident on imaging
• Failure to respond to 48 hours of IV antibiotics
• Intracranial complications develop 1

The percentage of cases requiring surgical intervention has increased significantly over time, from 4.3% to as high as 70% in some studies 3, suggesting increasing antibiotic resistance and disease severity.

Microbiology Considerations

Common pathogens to target:

• Streptococcus pneumoniae (28.57% of cases) 3
• Staphylococcus aureus (16.32% of cases) 3
• Other potential pathogens: Streptococcus pyogenes, Pseudomonas aeruginosa, Klebsiella pneumoniae 4

Important Clinical Pearls

• Do not delay treatment: Delayed intervention can lead to serious intracranial complications including brain abscess 1
• Prior antibiotic treatment is not protective: 80% of mastoiditis cases had received prior antibiotics 3, with studies showing 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission 1
• Obtain appropriate imaging: CT or MRI should be performed when clinical improvement doesn't occur within 48 hours to evaluate for complications 1, 5
• Consider tympanocentesis for culture: This becomes increasingly valuable in cases of antibiotic treatment failures to guide therapy 3

Treatment Algorithm

1. Initial Assessment:

   • Classify as uncomplicated or complicated mastoiditis
   • Obtain cultures when possible

2. Initial Treatment:

   • Start IV antibiotics (cloxacillin/flucloxacillin) 2
   • Perform myringotomy in most cases

3. Reassessment at 48 hours:

   • If improving: Continue IV antibiotics
   • If not improving: Obtain imaging and consider surgical intervention

4. Transition to Oral Therapy:

   • Once clinically improved with no evidence of bacteremia
   • Complete total 2-3 weeks of antibiotics 1

The increasing incidence of complicated cases requiring surgical intervention highlights the importance of early recognition and appropriate management of mastoiditis to prevent serious complications and reduce morbidity and mortality.