Treatment of Mastoiditis
The treatment of mastoiditis requires intravenous broad-spectrum antibiotics as first-line therapy, with surgical intervention indicated for complicated cases or those failing to respond to 48 hours of antibiotic therapy. 1
Classification and Initial Management
Mastoiditis treatment depends on proper classification:
Uncomplicated Mastoiditis
First-line treatment: Intravenous antibiotics for 7-10 days
- Recommended regimens 1:
- Cloxacillin/flucloxacillin IV 50 mg/kg QDS for 10 days
- Ceftriaxone IV
- Vancomycin plus piperacillin-tazobactam
- Vancomycin plus a carbapenem
- Vancomycin plus ceftriaxone and metronidazole
- Recommended regimens 1:
Myringotomy: Often performed to facilitate drainage 1
Duration: Total antibiotic course of 2-3 weeks, with transition to oral antibiotics once clinical improvement occurs 1
Complicated Mastoiditis
Defined by presence of:
- Subperiosteal abscess
- Bony erosion/coalescence
- Intracranial complications
- Failure to respond to 48 hours of IV antibiotics 1, 2
Surgical Management
Surgical intervention is indicated for:
- Subperiosteal abscess requiring drainage
- Bony erosion or coalescence
- Failure to respond to 48 hours of IV antibiotics
- Presence of intracranial complications 1
The primary surgical procedure is mastoidectomy, which removes infected mastoid air cells and provides drainage 1, 2.
Microbiology and Antibiotic Selection
Common causative organisms include:
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Haemophilus influenzae 3, 4
When selecting empiric antibiotics before culture results are available, an anti-staphylococcal agent should be included in the regimen 3.
Monitoring and Follow-up
- Daily evaluation during initial treatment
- Imaging (CT temporal bones with contrast) if no clinical improvement within 48 hours 5
- Transition to oral antibiotics once clinically improved with no evidence of bacteremia 1
Outpatient Management
In select cases of uncomplicated mastoiditis with periosteitis, outpatient management may be considered:
- Once-daily IM ceftriaxone
- Wide myringotomy
- Daily follow-up by combined otolaryngology and infectious disease team 6
However, this approach requires careful patient selection and close monitoring.
Complications to Monitor
Potential complications include:
- Subperiosteal and intracranial abscess
- Deep neck abscess
- Facial nerve palsy
- Meningitis/encephalitis
- Venous sinus thrombosis
- Seizures 5
Important Caveats
Prior antibiotic treatment for acute otitis media does not prevent mastoiditis; studies show 33-81% of patients with mastoiditis had received antibiotics before admission 1, 4
Delayed surgical intervention can lead to serious intracranial complications 1
The distribution of causative organisms in mastoiditis differs from that in acute otitis media, requiring broader antibiotic coverage 4
Truly uncomplicated mastoiditis (without any bony erosion) may be managed without mastoidectomy, while complicated cases generally require surgical intervention 2