What is the treatment for mastoiditis in adults?

Treatment of Mastoiditis in Adults

Mastoiditis in adults requires prompt treatment with broad-spectrum intravenous antibiotics as first-line therapy, with surgical intervention indicated for complicated cases or those failing to respond to medical management within 48 hours. 1

Initial Assessment and Classification

• Classify mastoiditis as:

  • Uncomplicated: Inflammation without abscess formation
  • Complicated: With subperiosteal abscess, bony erosion, or intracranial complications

• Key diagnostic features:

  • Erythema and edematous swelling over mastoid process
  • Protrusion of the auricle
  • History of acute otitis media
  • Fluctuant swelling suggesting subperiosteal abscess

Medical Management

First-Line Treatment

• Intravenous antibiotics for 7-10 days 1

  • Options include:
    • Cloxacillin/flucloxacillin IV 50 mg/kg QDS
    • Vancomycin plus piperacillin-tazobactam
    • Vancomycin plus a carbapenem
    • Vancomycin plus ceftriaxone and metronidazole

• Antibiotic selection should target common pathogens:

  • Streptococcus pneumoniae (28.6%)
  • Staphylococcus aureus (16.3%)
  • Streptococcus pyogenes
  • Pseudomonas aeruginosa
  • Mixed flora 2, 3

• Myringotomy to facilitate drainage and obtain cultures 1

Duration of Therapy

• Total antibiotic duration: 2-3 weeks 1
• Transition to oral antibiotics once:
  • Clinical improvement is observed
  • No evidence of bacteremia
  • Patient is afebrile for 24-48 hours

Surgical Management

Indications for Surgical Intervention

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

Surgical Procedures

• Mastoidectomy: Removal of infected mastoid air cells
• Subperiosteal abscess drainage: When fluctuant collection is present
• Tympanocentesis: For middle ear cultures in antibiotic treatment failures

Monitoring and Complications

Monitoring Response

• Daily clinical assessment
• Consider imaging (CT scan) if no improvement within 48 hours

Potential Complications

• Intracranial complications (still common in adults) 4:
  • Meningitis
  • Brain abscess
  • Lateral sinus thrombosis
  • Subdural empyema
• Other complications:
  • Facial nerve paralysis
  • Labyrinthitis
  • Petrositis

Important Clinical Considerations

• Adult mastoiditis may present with atypical features and insidious development 4
• Prior antibiotic treatment does not prevent mastoiditis development (54-80% of mastoiditis patients had received antibiotics) 1, 3
• The incidence of mastoiditis has been increasing in recent years 2
• Surgical intervention rates have increased significantly (from 4.3% to 70% in some studies) 2

Treatment Algorithm

1. Start IV antibiotics immediately after obtaining cultures
2. Perform myringotomy for drainage and culture
3. Assess response at 48 hours
4. If improving: continue IV antibiotics, then transition to oral
5. If not improving: obtain imaging and consider surgical intervention
6. Monitor for complications throughout treatment course

Remember that delayed surgical intervention when indicated can lead to serious intracranial complications with significant morbidity 1.