What is the treatment for mastoiditis?

Treatment of Mastoiditis

Mastoiditis requires prompt treatment with intravenous antibiotics as first-line therapy, with surgical intervention indicated for patients who fail to improve after 48 hours of antibiotics or who present with complications. 1

Diagnostic Approach

• High-resolution temporal bone CT scan with contrast is the first-line imaging modality to:
  • Assess bone destruction
  • Identify complications
  • Guide surgical planning 1
• MRI should be considered when:
  • Intracranial complications are suspected
  • Soft tissue extension needs better characterization
  • Venous sinus thrombosis is suspected 1

Treatment Algorithm

Initial Management

1. Intravenous Antibiotic Therapy

   • First-line options include:
     • Cloxacillin/flucloxacillin IV
     • Ceftriaxone IV
     • Vancomycin plus piperacillin-tazobactam
     • Vancomycin plus a carbapenem
     • Vancomycin plus ceftriaxone and metronidazole 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

2. Myringotomy with Culture

   • Should be performed at initial presentation for drainage and culture collection 1

Treatment Duration

• Total antibiotic therapy (IV + oral) typically lasts 2-3 weeks
• Oral therapy should continue for at least 7-10 days after IV therapy completion 1

Surgical Intervention

Indicated in the following scenarios:

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

Surgical options include:

• Mastoidectomy: Performed in up to 77% of complicated cases 2
• Subperiosteal abscess drainage: When present 1
• Neurosurgical intervention: For brain abscess management 1

Treatment Success Rates

• Conservative therapy with antibiotics alone: ~24.6% success rate 3
• Minor surgical procedures (excluding mastoidectomy): ~87.7% success rate 3
• Mastoidectomy: ~97% success rate 3

Complications and Monitoring

• Potential complications include:

  • Intracranial extension
  • Venous sinus thrombosis (observed in 3.2% of cases) 4
  • Facial nerve paralysis
  • Septicemia 1

• Risk factors for complications:

  • Young age (children and adolescents)
  • Immunocompromised status
  • Delayed treatment
  • Infection with virulent organisms 1

• Close follow-up is essential:

  • Patients should be reassessed within 48-72 hours of starting antibiotics 1
  • Recurrence rates of 4-8% have been reported, with higher risk in S. pneumoniae infections 1

Important Considerations

• Prior antibiotic treatment for acute otitis media does not reliably prevent mastoiditis, with studies showing 33-81% of mastoiditis patients had received antibiotics prior to admission 1
• Surgical failures requiring multiple procedures are more frequent with:
  • Presence of anaerobes or gram-negative bacteria
  • Surgical drainage without mastoidectomy 4
• If surgery is indicated, it should include mastoidectomy for better outcomes 4

Outpatient Management

• Select patients with acute mastoiditis and periosteitis may be managed as outpatients with:
  • Daily intramuscular ceftriaxone
  • Wide myringotomy
  • Daily visits by otolaryngology and infectious disease specialists 5
• This approach has shown a 96.8% clinical cure rate in appropriate candidates 5