What is the treatment for mastoiditis?

Treatment of Mastoiditis

The definitive treatment for mastoiditis requires immediate intravenous broad-spectrum antibiotics, with surgical intervention indicated for cases that fail to improve after 48 hours of medical therapy or show evidence of complications such as subperiosteal abscess or intracranial spread. 1, 2, 3

Diagnostic Approach

• High-resolution CT temporal bone with IV contrast is recommended to evaluate the extent of disease, bony erosion, and potential complications 1
• MRI with contrast is superior for detecting intracranial complications such as meningitis, cerebritis, subdural empyema, or brain abscess 2, 3
• Cultures from the mastoid and any abscess should be obtained to guide targeted antibiotic therapy, though cultures may be negative in up to 33-53% of cases 1, 3

Medical Management

• First-line treatment consists of immediate intravenous broad-spectrum antibiotics targeting common pathogens including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 2, 4
• Common antibiotic regimens include:
  • Cloxacillin/flucloxacillin 2g IV every 6 hours for adults 1
  • High-dose amoxicillin-clavulanate for coverage of beta-lactamase-producing organisms 2, 3
  • Cephalosporins administered intravenously, particularly effective against Streptococcus pneumoniae 4
• Antibiotic treatment alone has only a 10% success rate in acute mastoiditis, while antibiotics plus surgical intervention has a 22% success rate 1

Surgical Interventions

• Myringotomy with or without tympanostomy tube placement is recommended to provide drainage and obtain cultures 3
• Surgical management is indicated in the following scenarios:
  • Failure to improve after 48 hours of appropriate intravenous antibiotic therapy 2, 3
  • Presence of subperiosteal abscess (though some may be managed with needle aspiration) 1, 3
  • Evidence of cholesteatoma, which necessitates mastoidectomy rather than making it optional 1
  • Clinical deterioration at any point during treatment 2
  • Development of intracranial complications 2, 3

Specific Surgical Approaches

• Mastoidectomy is the definitive surgical treatment for acute mastoiditis with subperiosteal abscess and cholesteatoma 1
• Subperiosteal abscess formation indicates advanced disease, potentially requiring modified radical mastoidectomy 1
• Drainage of any subperiosteal abscess should be performed during the mastoidectomy procedure 1
• Significant conductive hearing loss suggests extensive middle ear involvement, necessitating surgical intervention 1

Postoperative Care

• Continue intravenous antibiotics for 7-10 days, then transition to oral antibiotics based on culture results 1
• Close monitoring for clinical improvement is essential 3

Important Caveats

• Prior antibiotic treatment for acute otitis media does not eliminate the risk of developing mastoiditis, as 33-81% of patients with mastoiditis had received antibiotics before diagnosis 1, 3, 4
• The most common pathogens in mastoiditis are Streptococcus pneumoniae, followed by Streptococcus pyogenes, Staphylococcus aureus, and Haemophilus influenzae 4, 5
• The incidence of surgical intervention for mastoiditis has increased significantly in recent years, with one study showing an eight-fold increase in surgical treatments compared to previous years 6
• Complications of mastoiditis can be extracranial (subperiosteal abscess), intratemporal (facial nerve palsy, labyrinthitis), or intracranial (subdural abscess, brain abscess), with potentially life-threatening consequences 4, 7
• Conservative treatment with antibiotics and myringotomy can be successful in approximately 68% of cases without complications 8