What is the treatment for chronic mastoiditis?

Treatment for Chronic Mastoiditis

The treatment of chronic mastoiditis requires a combination of broad-spectrum intravenous antibiotics and surgical intervention, with mastoidectomy being the definitive treatment in most cases. 1

Initial Assessment and Classification

• Distinguish between uncomplicated and complicated mastoiditis:

  • Uncomplicated: Limited to mastoid air cells without abscess formation
  • Complicated: Presence of subperiosteal abscess, bony erosion, or intracranial complications

• Common presenting symptoms:

  • Otalgia (ear pain)
  • Chronic otorrhea (ear discharge)
  • Hearing loss
  • Retroauricular swelling, erythema, and tenderness 2

Medical Management

Antibiotic Therapy

• First-line intravenous antibiotic options:

  • Cloxacillin/flucloxacillin IV 50 mg/kg QDS for 10 days 1
  • Alternative regimens:
    • Vancomycin plus piperacillin-tazobactam
    • Vancomycin plus a carbapenem
    • Vancomycin plus ceftriaxone and metronidazole 1

• Antibiotic selection should target common pathogens:

  • Chronic mastoiditis: Pseudomonas aeruginosa, Enterobacteriaceae, Staphylococcus aureus, and anaerobic bacteria 3

• Duration of therapy:

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

Drainage Procedures

• Myringotomy with or without tympanostomy tube placement to facilitate drainage 3
• Continue IV antibiotics if the patient shows improvement 1

Surgical Management

• Surgical intervention is indicated for:

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

• Surgical procedures:

  • Simple mastoidectomy with tympanostomy tube placement for uncomplicated cases
  • Modified radical mastoidectomy for extensive disease or cholesteatoma
  • Radical mastoidectomy only if no improvement after simple mastoidectomy 3

• Subperiosteal abscess drainage should be performed when present 1

Monitoring and Follow-up

• Assess clinical improvement within 48 hours of initiating treatment
• Obtain appropriate imaging (CT scan) if clinical improvement doesn't occur within 48 hours 1
• Monitor for potential complications:
  • Intracranial complications (brain abscess, meningitis)
  • Sigmoid sinus thrombosis
  • Facial nerve paralysis

Important Considerations and Pitfalls

• Delayed surgical intervention can lead to serious intracranial complications, with brain abscess having an estimated incidence of 1 per million per annum 1
• CT imaging is essential for determining the extent of disease and identifying complications 2
• Prior antibiotic treatment does not reliably prevent mastoiditis progression, as studies show 33-81% of patients diagnosed with acute mastoiditis had received antibiotics prior to admission 1
• Failure to obtain appropriate imaging when clinical improvement doesn't occur within 48 hours may miss developing complications 1

Special Populations

• In children with acute mastoiditis with periosteitis, outpatient management with daily intramuscular ceftriaxone and close monitoring by a combined team of otolaryngologists and infectious disease specialists may be considered in select cases 4
• For specific infections (e.g., tuberculosis), additional specialized treatment may be required 2