What is the treatment for Mastoiditis?

Treatment of Mastoiditis

The treatment of mastoiditis requires prompt intervention with intravenous antibiotics and consideration of surgical management, with mastoidectomy indicated for patients who fail to improve after 48 hours of IV antibiotics or those with complications such as subperiosteal abscess or intracranial extension. 1

Diagnostic Approach

Imaging

• First-line imaging: High-resolution temporal bone CT scan with contrast
  • Assesses bone destruction
  • Identifies complications
  • Guides surgical planning 1
• Complementary imaging: MRI with contrast when intracranial complications are suspected
  • Superior for detecting intracranial complications
  • Better characterization of soft tissue extension
  • Evaluation of venous sinus thrombosis 2, 1

Antibiotic Therapy

Initial IV Antibiotic Options

• First-line regimens:
  • Cloxacillin/flucloxacillin IV
  • Ceftriaxone IV
  • Vancomycin plus piperacillin-tazobactam
  • Vancomycin plus a carbapenem
  • Vancomycin plus ceftriaxone and metronidazole 1

Duration and Transition

• Total antibiotic therapy: 2-3 weeks
• Initial IV therapy followed by oral therapy
• Oral therapy should continue for at least 7-10 days after completion of IV therapy 1

Special Considerations

• 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
• For brain abscesses due to otomastoiditis: Third-generation cephalosporin combined with metronidazole IV for 6-8 weeks 1

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
• Mastoidectomy: Required in approximately 77% of cases 1, 3
• Subperiosteal abscess drainage: When present 1
• Neurosurgical intervention: For brain abscess aspiration or excision 1

Treatment Algorithm

1. Initial presentation:

   • Obtain high-resolution CT temporal bone with contrast
   • Start IV antibiotics immediately
   • Perform myringotomy for drainage and culture

2. After 48 hours:

   • If improving: Continue IV antibiotics
   • If not improving or worsening: Consider mastoidectomy 1

3. Complications management:

   • Intracranial extension: Add MRI imaging, neurosurgical consultation
   • Venous sinus thrombosis: Consider anticoagulation
   • Facial nerve paralysis: Urgent surgical decompression may be needed 1

Important Considerations

Microbiology

• Common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 3, 4
• Presence of anaerobes or gram-negative bacteria is associated with higher surgical failure rates 4

Complications and Outcomes

• Intracranial complications occur in a significant number of cases despite antibiotic therapy 5
• Recurrence rates of 4-8% have been reported, with S. pneumoniae infections having a higher recurrence risk 1, 4

Pitfalls to Avoid

• Don't delay imaging: Clinical presentation can be subtle and nonspecific, especially in early stages 6
• Don't rely solely on clinical findings: Only a minority of patients present with characteristic physical findings 6
• Don't assume prior antibiotics prevent mastoiditis: 54-72% of patients with mastoiditis had received antibiotics prior to diagnosis 1, 3
• Don't perform surgical drainage without mastoidectomy: This is associated with higher failure rates 4
• Don't use narrow-spectrum antibiotics empirically: Coverage should include common otitis media pathogens plus anti-staphylococcal activity 5