What is the recommended treatment for Otomastoiditis?

Treatment of Otomastoiditis

For otomastoiditis, the recommended treatment is a combination of surgical intervention with mastoidectomy and intravenous broad-spectrum antibiotics, particularly in cases with cortical breach or subperiosteal abscess. 1

Diagnosis and Initial Assessment

• Accurate diagnosis is essential and should include:
  • Clinical examination for retroauricular inflammation, displacement of the pinna, swelling, erythema, and tenderness
  • Otoscopic examination to confirm acute otitis media
  • CT imaging to evaluate extent of mastoid involvement and potential complications

Treatment Algorithm

1. Antibiotic Therapy

• Initial Treatment:

  • Start intravenous broad-spectrum antibiotics immediately
  • First-line: High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 1
  • Alternative: Ceftriaxone 50 mg/kg/day IV 1

• Duration:

  • Continue IV antibiotics for at least 48-72 hours after surgery 1
  • Complete a total 10-14 day course of antibiotics (IV followed by oral) 1

2. Surgical Management

• Indications for immediate surgical intervention:

  • Post-auricular abscess
  • CT evidence of acute mastoiditis with cortical breach
  • Subperiosteal abscess formation
  • Failure to respond to IV antibiotics within 48 hours 2

• Surgical Procedures:

  • Cortical mastoidectomy to drain the mastoid and remove infected bone 1
  • Myringotomy may be appropriate in early cases or as an adjunct procedure 2

3. Post-Surgical Management

• Transition to oral antibiotics based on:
  • Clinical improvement
  • Culture results (if available)
  • Complete 10-14 day total antibiotic course 1
• Close follow-up to monitor for resolution and complications

Special Considerations

Antibiotic Resistance

• Recent studies show increasing resistance of common pathogens (S. pneumoniae, S. aureus) to amoxicillin and amoxicillin-clavulanate 3
• Consider culture-guided antibiotic therapy when possible

Outpatient Management

• Select cases of acute mastoiditis with periosteitis may be managed as outpatients with:
  • Daily intramuscular ceftriaxone
  • Wide myringotomy
  • Daily follow-up by otolaryngology and infectious disease specialists 4
• This approach should be reserved for carefully selected patients without signs of intracranial complications

Complications to Monitor

• Intracranial complications requiring additional interventions:
  • Brain abscess
  • Meningitis
  • Sigmoid sinus thrombosis
  • Facial nerve paralysis
  • Hearing loss 1

Pitfalls to Avoid

1. Delaying surgical intervention when indicated, which can lead to serious intracranial complications
2. Inadequate antibiotic coverage or duration
3. Failure to obtain appropriate imaging when complications are suspected
4. Overlooking underlying chronic conditions such as cholesteatoma 2

Otomastoiditis represents a serious progression of acute otitis media that requires aggressive management. While the American Academy of Otolaryngology-Head and Neck Surgery guidelines emphasize surgical intervention with mastoidectomy plus IV antibiotics for cases with cortical breach or abscess formation 1, early cases may respond to IV antibiotics alone. However, failure to improve within 48 hours should prompt surgical intervention to prevent potentially life-threatening complications.