What is the appropriate treatment for a patient with acute mastoiditis and subperiosteal abscess secondary to chronic otitis media, with significant hearing loss?

Management of Acute Mastoiditis with Subperiosteal Abscess and Cholesteatoma

Surgical intervention with mastoidectomy is the definitive treatment for this patient with acute mastoiditis, subperiosteal abscess, cholesteatoma, and significant hearing loss.

Initial Management

• Begin immediate intravenous broad-spectrum antibiotics (cloxacillin/flucloxacillin 2g IV every 6 hours for adults) while preparing for surgical intervention 1
• Obtain high-resolution CT temporal bone with IV contrast to fully evaluate the extent of disease, bony erosion, and potential intracranial complications 2
• MRI may be complementary if intracranial complications are suspected, as it has higher sensitivity for detecting these complications 2

Surgical Management

• Mastoidectomy is the definitive treatment for this case due to the presence of both subperiosteal abscess and cholesteatoma 2
• While some subperiosteal abscesses can be managed with needle aspiration and myringotomy, the presence of cholesteatoma necessitates mastoidectomy for disease clearance 2
• The significant hearing loss (71dB air conduction threshold) indicates substantial middle ear involvement requiring surgical intervention 2

Surgical Approach Considerations

• Modified radical mastoidectomy is likely required due to:
  • Presence of cholesteatoma requiring complete removal 3
  • Subperiosteal abscess formation indicating advanced disease 2
  • Significant conductive hearing loss suggesting extensive middle ear involvement 2

Perioperative Management

• Drainage of the subperiosteal abscess should be performed during the mastoidectomy procedure 2
• Consider tympanostomy tube placement to ensure continued middle ear drainage 4
• Obtain cultures from the mastoid and abscess to guide targeted antibiotic therapy 1

Postoperative Care

• Continue intravenous antibiotics for 7-10 days, then transition to oral antibiotics based on culture results 1
• Regular follow-up to monitor:
  • Resolution of infection 5
  • Hearing status with repeat audiometry 5
  • Potential need for second-stage hearing reconstruction depending on the extent of disease 3

Prognosis

• With appropriate surgical intervention and antibiotic therapy, most patients have favorable outcomes 3
• Potential complications to monitor include:
  • Permanent hearing loss (occurs in approximately 2.7% of cases) 3
  • Need for surgical reintervention (approximately 5.4% of cases) 3
  • Neurological sequelae (rare but possible in 5.4% of cases) 3

Important Caveats

• Conservative management with antibiotics alone has only a 10% success rate in acute mastoiditis, while antibiotics plus mastoidectomy has a 22% success rate 2
• The presence of cholesteatoma significantly alters the management approach, making mastoidectomy necessary rather than optional 2
• Prior antibiotic treatment does not eliminate the risk of developing complications, as 33-81% of patients with mastoiditis had received antibiotics before diagnosis 2