How is mastoiditis treated?

Treatment of Mastoiditis

Mastoiditis should be treated with intravenous antibiotics (such as ampicillin-sulbactam or ceftriaxone) with early otolaryngology consultation, and surgical intervention for cases with subperiosteal abscess or those failing to improve after 48 hours of medical therapy. 1, 2

Clinical Presentation and Diagnosis

• Key clinical findings:

  • Postauricular erythema and tenderness
  • Protrusion of the pinna
  • External auditory canal swelling
  • Fever and systemic symptoms
  • Often preceded by acute otitis media 1

• Diagnostic approach:

  • CT temporal bone with IV contrast is the preferred initial imaging for suspected complications 2
  • MRI is superior for detecting intracranial complications 2
  • Laboratory tests may show inflammatory markers but normal values don't exclude the diagnosis 1

Treatment Algorithm

1. Initial Management

• Intravenous antibiotics:
  • First-line: Ampicillin-sulbactam or ceftriaxone 1
  • Coverage should include Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus (most common pathogens) 3, 1
  • Immediate otolaryngology consultation 1

2. Surgical Interventions (based on presentation)

• Uncomplicated mastoiditis:

  • Trial of IV antibiotics with or without myringotomy 2
  • Swedish data shows 10% of cases respond to antibiotics alone, 68% to antibiotics with myringotomy 2

• Mastoiditis with subperiosteal abscess:

  • Surgical drainage required - either needle aspiration or mastoidectomy 2
  • Some cases (57% in one Greek series) can be managed with needle aspiration and myringotomy without mastoidectomy 2

• Mastoiditis failing medical therapy:

  • If no improvement after 48 hours or clinical deterioration, obtain CT scan 2
  • Proceed to mastoidectomy if imaging shows complications or patient continues to deteriorate 2

3. Management of Complications

• Intracranial complications (meningitis, brain abscess, venous sinus thrombosis):
  • MRI is preferred over CT for detection 2
  • Neurosurgical consultation
  • Extended antibiotic coverage
  • Surgical intervention based on specific complication 3

Important Considerations

• Despite the advent of antibiotics, mastoiditis remains a serious and potentially lethal condition 4
• Antibiotic pretreatment for acute otitis media cannot invariably prevent the development of mastoiditis, even with penicillin-sensitive pathogens 5
• Mastoiditis may be the first clinical sign of middle ear infection, especially in very young children 5
• Regular reassessment is critical - failure to improve within 48 hours should prompt imaging and consideration of surgical intervention 2

Pitfalls to Avoid

• Delaying otolaryngology consultation
• Failing to obtain appropriate imaging when patients don't respond to initial therapy
• Assuming antibiotic treatment for acute otitis media will prevent all cases of mastoiditis
• Overlooking potential intracranial complications, which can be clinically subtle but have serious consequences 6

The treatment approach has evolved from routine mastoidectomy to more conservative management with antibiotics and myringotomy in many cases, but surgical intervention remains necessary for complicated cases or those failing medical management 2, 4.