What is the recommended treatment for Otomastoiditis?

Treatment of Otomastoiditis

The recommended treatment for otomastoiditis involves initial intravenous antibiotics, with or without myringotomy, and progression to mastoidectomy if there is no improvement within 48 hours or if complications develop. 1

Initial Assessment and Management

• Otomastoiditis is a serious complication of acute otitis media that requires prompt and aggressive treatment to prevent intracranial complications 1
• Initial management should include:
  • Intravenous broad-spectrum antibiotics as first-line treatment 1
  • Consideration of myringotomy with or without tympanostomy tube insertion 1
  • Pain management as a critical component of care 1

Antibiotic Therapy

• Intravenous antibiotics should be started immediately upon diagnosis 1
• Common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 2, 3
• Antibiotic selection should consider:
  • High rates of resistance to amoxicillin and amoxicillin-clavulanate have been reported 4
  • Coverage for both gram-positive and gram-negative organisms is essential 3
  • Samples for bacterial culture should be obtained prior to antibiotic administration whenever possible 3

Surgical Management Algorithm

1. Initial Conservative Approach (0-48 hours):

   • Intravenous antibiotics with or without myringotomy 1
   • If subperiosteal abscess is present, needle aspiration may be considered 1

2. Reassessment at 48 hours:

   • If improving: continue medical management 1
   • If not improving or worsening: proceed to imaging and consider surgical intervention 1

3. Surgical Intervention Indications:

   • Failure to respond to IV antibiotics within 48 hours 1
   • Presence of coalescent mastoiditis 5
   • Intracranial complications 1
   • Subperiosteal abscess (though some may be managed with needle aspiration) 1

4. Type of Surgical Intervention:

   • Mastoidectomy is the standard surgical approach for complicated cases 1, 4
   • Simple mastoidectomy for uncomplicated cases 6
   • More extensive procedures may be needed for intracranial complications 1

Imaging

• CT scanning should be performed if:
  • Patient fails to improve after 48 hours of IV antibiotics 1
  • There is clinical deterioration at any point 1
  • Intracranial complications are suspected 5
• CT can identify:
  • Coalescent mastoiditis (rarefying osteitis, coalescence of air cells) 5
  • Subperiosteal abscess 5
  • Intracranial complications 1, 5

Complications and Special Considerations

• Brain abscess is the most common intracranial complication 1
• Other complications include:
  • Sigmoid sinus thrombosis 1
  • Meningitis 3
  • Labyrinthitis 3
  • Facial nerve palsy 3
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 1
• Anticoagulation may be considered for sigmoid sinus thrombosis, though evidence is limited 1

Treatment Success Rates

• In a Swedish review, treatment success was achieved with:
  • Antibiotics alone: 10% of cases 1
  • Antibiotics plus myringotomy: 68% of cases 1
  • Antibiotics plus mastoidectomy: 22% of cases 1
• Surgical intervention rates have increased in recent years, suggesting more aggressive disease or antibiotic resistance 2

Pitfalls and Caveats

• Prior antibiotic treatment does not prevent development of mastoiditis; 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission 1
• Delayed diagnosis and inadequate initial antibiotic therapy are associated with worse outcomes and higher complication rates 4
• Rural populations may present later with more advanced disease, requiring more aggressive intervention 4
• Antibiotic resistance patterns should be considered when selecting empiric therapy 4, 3