What is the recommended treatment for mastoiditis in the emergency department (ED)?

Treatment of Mastoiditis in the Emergency Department

The recommended first-line treatment for mastoiditis in the emergency department is intravenous broad-spectrum antibiotics, specifically cloxacillin/flucloxacillin at a dose of 50 mg/kg QDS for 10 days, with ceftriaxone as a second-line option. 1, 2

Initial Assessment and Management

• Mastoiditis is a serious complication of acute otitis media requiring prompt and aggressive treatment to prevent intracranial complications 2, 3
• Key clinical features distinguishing mastoiditis from uncomplicated acute otitis media include:
  • Mastoid tenderness
  • Retroauricular swelling
  • Protrusion of the auricle 4
• CT of the temporal bones with intravenous contrast is the recommended imaging modality if diagnosis is uncertain 3

Antibiotic Therapy

• First-line antibiotic therapy:
  • Cloxacillin/flucloxacillin IV: 50 mg/kg QDS for 10 days 1
  • For adults, typical dosing is 2g every 6 hours IV 1
• Second-line antibiotic therapy:
  • Ceftriaxone IV: 50-80 mg/kg daily 1
• Common pathogens to target:
  • Streptococcus pneumoniae (28.57% of cases)
  • Staphylococcus aureus (16.32% of cases) 5

Surgical Management

• Initiate antibiotics immediately upon diagnosis 2

• Reassess after 48 hours of IV antibiotics 2

• Consider surgical intervention if:

  • No clinical improvement after 48 hours of IV antibiotics
  • Development of complications
  • Presence of subperiosteal abscess 2, 6

• Surgical options include:

  • Myringotomy with or without tympanostomy tube insertion
  • Mastoidectomy for complicated cases 2, 6

Treatment Algorithm

1. Initial treatment (0-48 hours):

   • Start IV cloxacillin/flucloxacillin 1
   • Consider myringotomy for drainage 2, 7
   • Provide appropriate pain management 2

2. Reassessment at 48 hours:

   • If improving: continue IV antibiotics 2
   • If not improving or worsening: obtain CT scan and consider surgical intervention 2, 3

3. Surgical intervention indications:

   • Subperiosteal abscess
   • Intracranial complications
   • Failure to respond to antibiotics 2, 6

Complications to Monitor

• Brain abscess (most common intracranial complication)
• Sigmoid sinus thrombosis
• Facial nerve palsy
• Meningitis/encephalitis
• Deep neck abscess
• Seizures 2, 3

Important Caveats

• Prior antibiotic treatment does not prevent the development of mastoiditis, with 33-81% of patients diagnosed with acute mastoiditis having received antibiotics before admission 2, 5
• Cultures from mastoid infections may be negative in up to 33-53% of cases, emphasizing the importance of clinical diagnosis 4
• Treatment success rates vary:
  • Antibiotics alone: 10% success
  • Antibiotics plus myringotomy: 68% success
  • Antibiotics plus mastoidectomy: 22% success 2
• Early mastoidectomy may prevent serious complications in cases not responding to initial therapy 6