What is the treatment for mastoiditis?

Treatment of Mastoiditis

The first-line treatment for mastoiditis includes intravenous antibiotics, with surgical intervention indicated if there is no improvement after 48 hours of antibiotic therapy or if complications are present. 1

Diagnostic Approach

• High-resolution temporal bone CT scan with contrast is the first-line imaging modality to assess bone destruction and identify complications
• MRI with contrast is recommended when intracranial complications are suspected
• Myringotomy for drainage and culture should be performed at initial presentation

Antibiotic Treatment

Intravenous antibiotics are the cornerstone of initial management:

First-line antibiotic options:

• 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

Duration of therapy:

• 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, 2

Surgical Management

Surgical intervention is indicated in specific scenarios:

Indications for surgery:

1. Lack of response to 48 hours of IV antibiotics
2. Presence of subperiosteal abscess
3. Evidence of bone erosion/coalescence
4. Development of intracranial complications 1

Surgical procedures:

• Myringotomy/tympanostomy: For drainage and culture collection
• Subperiosteal abscess drainage: When present
• Mastoidectomy: For cases not responding to antibiotics or with complications 3

Recent studies show a trend toward early surgical intervention, with mastoidectomy being performed in up to 77% of cases 3. This approach may help prevent serious complications and recurrence of acute mastoiditis.

Management 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, then transition to oral therapy
   • If not improving or worsening: Consider mastoidectomy 1

3. For complicated cases:

   • Subperiosteal abscess: Drainage procedure + antibiotics
   • Intracranial complications: Neurosurgical consultation and appropriate intervention
   • Sigmoid sinus thrombosis: Anticoagulation may be required 4

Monitoring and Follow-up

• Close follow-up is essential to monitor for potential complications
• Patients should be reassessed within 48-72 hours of starting antibiotics
• Total duration of therapy (IV + oral) typically 2-3 weeks 1

Complications to Monitor

• Intracranial extension
• Venous sinus thrombosis
• Facial nerve paralysis
• Septicemia 1

Important Considerations

• Prior antibiotic treatment for acute otitis media does not reliably prevent mastoiditis, with studies showing 33-81% of patients diagnosed with acute mastoiditis had received antibiotics prior to admission 1
• Recurrence rates of approximately 4-8% have been reported, highlighting the importance of adequate antibiotic coverage and duration of therapy 1
• Some studies suggest a shift toward more conservative management, with successful outpatient treatment possible in selected cases 5, 6
• However, the most recent evidence supports early surgical intervention to prevent serious complications 3