What is the recommended management for otomastoiditis?

Management of Otomastoiditis

The recommended management for otomastoiditis includes intravenous antibiotics as first-line treatment, with surgical intervention reserved for complicated cases or those failing to respond to medical therapy within 48 hours. 1

Classification and Diagnosis

Proper management begins with accurate classification:

• Uncomplicated otomastoiditis: Inflammation of the mastoid air cells without abscess formation or bony erosion
• Complicated otomastoiditis: Presence of subperiosteal abscess, bony erosion/coalescence, or intracranial complications

Key diagnostic findings include:

• Retroauricular swelling, erythema, and tenderness
• Displacement of the pinna
• Otomicroscopic evidence of acute otitis media
• Imaging (CT scan) to confirm diagnosis and evaluate complications 2

Medical Management

First-line Treatment

• Intravenous antibiotics for 7-10 days 1:

  • Cloxacillin/flucloxacillin IV 50 mg/kg QDS for 10 days
  • Ceftriaxone IV (once daily dosing) 3, 4
  • Alternative regimens: vancomycin plus piperacillin-tazobactam, vancomycin plus a carbapenem, or vancomycin plus ceftriaxone and metronidazole 1

• Myringotomy should be performed to facilitate drainage 1

• Total antibiotic duration: 2-3 weeks, with transition to oral antibiotics once clinically improved 1

Monitoring Response

• Assess clinical improvement within 48 hours of initiating IV antibiotics
• If no improvement occurs within 48 hours, surgical intervention should be considered 1, 5
• Obtain appropriate imaging when clinical improvement doesn't occur within 48 hours 1

Surgical Management

Surgical intervention is indicated for:

• Subperiosteal abscess
• Bony erosion/coalescence
• Failure to respond to 48 hours of IV antibiotics
• Intracranial complications 1, 5

The primary surgical procedure is mastoidectomy, with the extent determined by the degree of disease involvement 5.

Special Considerations

Outpatient Management

• Selected patients with acute mastoiditis with periosteitis may be managed as outpatients with daily intramuscular ceftriaxone after myringotomy 4
• This requires close monitoring by a combined team of otolaryngologists and infectious disease specialists

Tuberculous Otomastoiditis

• Requires specialized diagnosis with direct culture of Mycobacterium tuberculosis or molecular techniques
• Treatment involves surgical intervention combined with prolonged antituberculosis therapy 6

Chronic Otomastoiditis

• Often associated with cholesteatoma (49.31% of cases) 7
• May require more extensive surgical procedures
• Antibiotic resistance patterns should be considered, particularly for Streptococcus pneumoniae and Staphylococcus aureus 7

Complications and Prevention

• Delayed surgical intervention can lead to serious intracranial complications, including brain abscess 1
• Prior antibiotic treatment does not reliably prevent progression to mastoiditis, with studies showing 33-81% of patients diagnosed with acute mastoiditis had received antibiotics prior to admission 1

Follow-up Care

• Regular follow-up is essential to monitor for resolution of infection and potential complications
• Audiometric evaluation should be performed to assess for hearing loss once the acute infection has resolved

The management approach should be aggressive and timely to prevent serious complications that can result from untreated or inadequately treated otomastoiditis.