What is the initial workup and treatment for a patient presenting with right-sided mastoid tenderness?

Initial Workup and Treatment for Right-Sided Mastoid Tenderness

The initial workup for a patient presenting with right-sided mastoid tenderness should include high-resolution temporal bone CT scan with contrast, followed by empiric IV antibiotics and myringotomy for drainage and culture. 1

Diagnostic Approach

Clinical Evaluation

• Assess for classic symptoms:
  • Postauricular swelling, erythema, or tenderness
  • Protrusion of the auricle
  • Fever and ear pain
  • Ear discharge
  • Signs of concurrent middle ear infection 1

Imaging

• First-line imaging: High-resolution temporal bone CT scan with contrast

  • Evaluates bone destruction
  • Identifies complications
  • Guides surgical planning 1

• Secondary imaging: MRI with contrast (if intracranial complications suspected)

  • Superior for detecting intracranial extension
  • Better characterizes soft tissue involvement
  • Evaluates for venous sinus thrombosis 1

Laboratory Studies

• Complete blood count
• Blood cultures (if systemic symptoms present)
• Ear drainage culture (if present) or culture from myringotomy 1

Treatment Algorithm

Step 1: Initial Management

• Begin IV antibiotics immediately after obtaining cultures

  • First-line options:
    • Ceftriaxone IV
    • Vancomycin plus piperacillin-tazobactam
    • Vancomycin plus ceftriaxone and metronidazole 1

• Perform myringotomy for drainage and culture collection 1

Step 2: Assessment at 48 Hours

• If improving:

  • Continue IV antibiotics
  • Consider transition to oral therapy when clinically stable

• If not improving or worsening:

  • Consider mastoidectomy
  • Evaluate for complications requiring surgical intervention 1

Step 3: Complete Treatment Course

• Total antibiotic duration: 2-3 weeks
  • IV therapy initially (typically 5-7 days)
  • Oral therapy for at least 7-10 days after IV completion 1

Indications for Surgical Intervention

• Lack of clinical improvement after 48 hours of IV antibiotics
• Presence of subperiosteal abscess
• Evidence of bone erosion or coalescence
• Development of intracranial complications 1

Potential Complications to Monitor

• Intracranial extension (meningitis, brain abscess)
• Venous sinus thrombosis
• Facial nerve paralysis
• Septicemia 1

Important Clinical Considerations

• Prior antibiotic treatment for acute otitis media does not reliably prevent mastoiditis
  • Studies show 33-81% of mastoiditis patients had received antibiotics prior to diagnosis 1
• The incidence of mastoiditis has been increasing in recent years, with more cases requiring surgical intervention 2
• Causative organisms differ from those in acute otitis media
  • Common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 3
• Truly uncomplicated mastoiditis (without any bony erosion) may be managed without mastoidectomy 4
• Adult mastoiditis may present with atypical features and higher complication rates, particularly in elderly patients 5

Close follow-up is essential, with reassessment within 48-72 hours of starting antibiotics to monitor for potential complications and treatment response 1.