What are the symptoms and treatment options for mastoiditis?

Mastoiditis Symptoms and Treatment

Mastoiditis is characterized by mastoid tenderness, retroauricular swelling, and protrusion of the auricle, which distinguish it from uncomplicated acute otitis media and require prompt treatment with intravenous antibiotics, with surgical intervention reserved for cases that fail to improve after 48 hours of medical therapy or show evidence of complications. 1

Clinical Presentation

Key Symptoms

• Mastoid tenderness, retroauricular swelling, and protrusion of the auricle are the hallmark signs of mastoiditis 1
• Pain and fever lasting more than 4 days are common harbingers of incipient acute mastoiditis 2
• Similar tympanic membrane findings to acute otitis media (bulging, erythema) are typically present 1
• Otorrhea may be present if the tympanic membrane has ruptured 1

Warning Signs of Complications

• Persistent otorrhea, otalgia, headache, prolonged high fever, and neurological signs may indicate development of intracranial complications 3
• Clinical signs such as headache, vertigo, meningismus, neck rigidity, seizures, or neurological deficits suggest complications like subperiosteal abscess, labyrinthitis, meningitis, intracranial abscess, subdural empyema, or dural venous sinus thrombosis 4

Diagnostic Approach

• CT temporal bone is the preferred initial imaging modality for suspected mastoiditis 5
• MRI with contrast is superior for detecting intracranial complications such as meningitis, cerebritis, subdural empyema, or brain abscess 5
• Imaging is crucial for early diagnosis of complications and immediate appropriate treatment 4

Treatment Algorithm

Initial Management

• Intravenous broad-spectrum antibiotics targeting common pathogens including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 5
• Myringotomy with or without tympanostomy tube placement to provide drainage and obtain cultures 6
• High-dose amoxicillin-clavulanate is recommended as an alternative option for antibiotic regimens 6

Surgical Intervention Criteria

• Failure to improve after 48 hours of appropriate intravenous antibiotic therapy 6
• Presence of subperiosteal abscess (though some may be managed with needle aspiration) 6
• Evidence of intracranial complications on imaging, such as brain abscess or meningitis 6
• Clinical deterioration despite appropriate medical therapy 5

Management of Complications

• For intracranial complications, MRI with contrast is superior to CT for evaluation of intracranial spread 6
• Anticoagulation may be considered for sigmoid sinus thrombosis in the absence of contraindications 6
• Surgical treatments such as incision of abscesses, mastoidectomy, and neurosurgical procedures may be required for severe complications 7

Important Considerations and Pitfalls

• Mastoiditis can develop despite prior antibiotic treatment for acute otitis media (33-81% of mastoiditis cases had received antibiotics previously) 1
• Cultures from mastoid infections may be negative in up to 33-53% of cases, emphasizing the importance of broad-spectrum empiric coverage 6
• Relying solely on otoscopic findings may miss mastoiditis; always examine the mastoid area in cases of severe or persistent acute otitis media 1
• While CT imaging is definitive for diagnosing mastoiditis, the initial clinical diagnosis should be made based on physical examination findings 1
• Mastoiditis is significantly more common in children than in adults, with the highest incidence in children 1-4 years of age 5