What is the recommended treatment for otomastoiditis?

Treatment of Otomastoiditis

The recommended treatment for otomastoiditis includes intravenous antibiotics as first-line therapy, with surgical intervention (mastoidectomy) reserved for cases that fail to respond to medical management within 48 hours or those with complications. 1

Initial Medical Management

Antibiotic Therapy

• First-line treatment: Intravenous antibiotics with broad coverage against common pathogens
  • Ceftriaxone (50 mg/kg IM or IV daily) is effective and can be administered once daily 2
  • Alternative options include:
    • Amoxicillin-clavulanate at high dose (90 mg/kg/day of amoxicillin component) 3
    • Coverage should target common pathogens: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa 4

Duration and Monitoring

• Initial treatment typically requires 7-10 days of therapy 5
• Daily evaluation by otolaryngology and infectious disease specialists is essential 5
• Clinical improvement should be evident within 48-72 hours of initiating antibiotics

Surgical Management

Indications for Surgical Intervention

• Failure to improve after 48 hours of appropriate antibiotic therapy 1
• Presence of subperiosteal abscess
• Development of intracranial complications
• Coalescent mastoiditis identified on imaging

Surgical Options

1. Myringotomy with or without tympanostomy tube placement

   • May be sufficient in early cases without extensive bone involvement
   • Allows for drainage and culture collection 4

2. Mastoidectomy

   • Indicated for coalescent mastoiditis or cases with complications
   • Simple mastoidectomy is typically sufficient for acute cases 6
   • More extensive procedures may be needed if cholesteatoma is present 7

3. Needle aspiration

   • May be considered for subperiosteal abscesses in select cases 1

Imaging

• CT scan is the preferred imaging modality for evaluating otomastoiditis 8
• Indications for CT include:
  • Suspected coalescent mastoiditis
  • Failure to respond to initial therapy
  • Suspected intracranial complications
  • Features on CT that suggest need for surgery include:
    • Rarefying osteitis
    • Coalescence of air cells
    • Subperiosteal abscess formation 8

Management Algorithm

1. Diagnosis confirmation

   • Clinical presentation (postauricular swelling, erythema, tenderness, displacement of pinna)
   • Otoscopic evidence of acute otitis media

2. Initial management

   • Intravenous antibiotics (ceftriaxone preferred)
   • Pain management
   • Consider myringotomy for drainage and culture

3. Reassessment at 48 hours

   • If improving: continue antibiotics
   • If not improving or worsening: obtain CT scan and consider surgical intervention

4. Surgical decision-making

   • Uncomplicated cases without neurologic deficits: continue antibiotics with myringotomy
   • Cases with subperiosteal abscess: drainage (needle aspiration or surgical)
   • Cases with coalescent mastoiditis or intracranial complications: mastoidectomy

Special Considerations

• Outpatient management may be possible in select cases with daily follow-up and parenteral antibiotics 5
• Antibiotic resistance is increasing, particularly for S. pneumoniae and S. aureus, which may necessitate broader coverage 7
• Intracranial complications (meningitis, brain abscess, sinus thrombosis) require aggressive management with neurosurgical consultation 1

Complications to Monitor

• Intracranial spread (brain abscess, meningitis)
• Sigmoid sinus thrombosis
• Facial nerve palsy
• Labyrinthitis
• Hearing loss

The management of otomastoiditis has evolved with improved antibiotic therapy, but surgical intervention remains an important component of treatment for cases that fail to respond to medical management or develop complications.