From the Research
The next best step for a 3-year-old with suspected mastoiditis is immediate referral to an otolaryngologist (ENT specialist) for evaluation and management, along with obtaining a contrast-enhanced CT scan of the temporal bone to confirm the diagnosis and assess the extent of infection. While awaiting specialist consultation, empiric intravenous antibiotics should be initiated, typically a combination of a third-generation cephalosporin (such as ceftriaxone 50-75 mg/kg/day) plus metronidazole (30 mg/kg/day divided every 8 hours) or vancomycin (40-60 mg/kg/day divided every 6 hours) to cover common pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and anaerobes, as suggested by 1.
Key Considerations
- Mastoiditis is a serious complication of acute otitis media where infection spreads from the middle ear to the mastoid air cells, potentially leading to intracranial complications if untreated.
- The child should be hospitalized for close monitoring and administration of IV antibiotics.
- Surgical intervention with mastoidectomy may be necessary if there is no improvement with antibiotics within 24-48 hours, or if complications such as abscess formation are present, as indicated by 1 and 2.
- Pain management with appropriate weight-based dosing of acetaminophen or ibuprofen should also be provided.
Management Approach
- The management protocol should include initiating broad-spectrum intravenous antibiotic treatment, as recommended by 1.
- Mastoidectomy should be performed if the infection fails to be controlled after 48 hours of administering intravenous antibiotic therapy, as suggested by 1.
- Early mastoidectomy can prevent serious complications, and performing broad mastoidectomy with posterior attic and facial recess exposure can help prevent recurrence of acute mastoiditis, as observed in 1.
Evidence Summary
The most recent and highest quality study, 1, provides a comprehensive approach to the management of pediatric acute mastoiditis, emphasizing the importance of early diagnosis, appropriate antibiotic therapy, and surgical intervention when necessary. This study supports the recommendation for immediate referral to an ENT specialist and the initiation of empiric intravenous antibiotics, as well as the consideration for surgical intervention if there is no improvement with antibiotics within 24-48 hours.