What is the treatment for mastoiditis?

Treatment of Mastoiditis

The treatment of mastoiditis requires a combination of intravenous antibiotics and surgical intervention, with mastoidectomy indicated for patients who do not improve after 48 hours of IV antibiotics or those with complications such as subperiosteal abscess or intracranial extension. 1

Diagnostic Approach

• Imaging: High-resolution temporal bone CT scan with contrast is the first-line imaging modality to assess bone destruction, identify complications, and guide surgical planning 1
• MRI: Should be considered when intracranial complications are suspected or venous sinus thrombosis is a concern 1
• Cultures: Myringotomy for drainage and culture collection is essential for targeted antibiotic therapy 1

Antibiotic Therapy

First-line options:

• IV antibiotics:
  • Ceftriaxone IV (covers Streptococcus pneumoniae, the most common pathogen) 1, 2
  • Cloxacillin/flucloxacillin IV (for Staphylococcus coverage) 1
  • For severe cases: Vancomycin plus piperacillin-tazobactam or vancomycin plus a carbapenem 1

For penicillin-allergic patients:

• Clindamycin (10-20 mg/kg/day in 3 divided doses for children; 300-450 mg 3 times daily for adults) 1

Duration:

• Total antibiotic therapy typically lasts 2-3 weeks
• IV antibiotics until clinical improvement, then transition to oral therapy
• Oral therapy should continue for at least 7-10 days after IV therapy completion 1, 2

Surgical Management

Indications for surgical intervention:

1. Failure to improve after 48 hours of IV antibiotics
2. Presence of subperiosteal abscess
3. Evidence of bone erosion/coalescence
4. Development of intracranial complications 1, 3

Surgical procedures:

• Myringotomy: Initial procedure for drainage and culture collection 1
• Subperiosteal abscess drainage: When present 1
• Mastoidectomy: Required in approximately one-third of cases 3, 4
• Neurosurgical intervention: For intracranial complications such as brain abscess 1

Treatment Algorithm

1. Initial presentation:

   • Obtain high-resolution CT temporal bone with contrast
   • Start IV antibiotics (ceftriaxone or cloxacillin/flucloxacillin)
   • Perform myringotomy for drainage and culture 1

2. After 48 hours:

   • If improving: Continue IV antibiotics until clinically stable, then transition to oral therapy
   • If not improving or worsening: Consider mastoidectomy 1, 3

3. For complicated cases:

   • Subperiosteal abscess: Drainage plus antibiotics
   • Intracranial complications: Neurosurgical consultation, appropriate imaging (MRI), and targeted antibiotics 1

Complications and Monitoring

• Potential complications: Intracranial extension, venous sinus thrombosis, facial nerve paralysis, and septicemia 1
• Risk factors for complications: Young age (children and adolescents), immunocompromised status, delayed treatment 1
• Follow-up: Close monitoring with reassessment within 48-72 hours of starting antibiotics 1
• Recurrence rate: Approximately 4-8%, with S. pneumoniae infections having a higher recurrence risk 1

Important Considerations

• While some studies suggest outpatient management with once-daily IM ceftriaxone may be possible in select cases 5, most patients with mastoiditis require hospitalization for IV antibiotics and close monitoring
• Conservative therapy (antibiotics alone) has a success rate of only 24.6%, while minor surgical procedures have a success rate of 87.7%, and mastoidectomy has a success rate of 97% 4
• Mastoiditis should be considered in patients with persistent otitis media or fever of unknown origin, as early clinical signs may be subtle 6