What is the management of otomastoiditis?

Management of Otomastoiditis

Otomastoiditis requires immediate treatment with intravenous broad-spectrum antibiotics as first-line therapy, with consideration for surgical intervention if there is no improvement within 48 hours. 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:
  • Immediate initiation of intravenous broad-spectrum antibiotics 1
  • Pain management as a critical component of care 1
  • Imaging with CT scan if the patient fails to improve after 48 hours of IV antibiotics or if clinical deterioration occurs at any point 1, 2

Antibiotic Therapy

• First-line treatment is intravenous broad-spectrum antibiotics with coverage for common pathogens including Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae 1, 3
• Ceftriaxone is an appropriate initial choice due to its coverage of common otomastoiditis pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus 3
• For patients who fail initial therapy, antibiotic choices should be guided by culture results when available 4
• In cases of treatment failure, consider:
  • Clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis 4
  • For multidrug-resistant organisms, especially S. pneumoniae serotype 19A, newer antibiotics may be indicated 4, 5

Surgical Management

• A stepwise approach to surgical management is recommended:
  • Initial conservative approach with IV antibiotics with or without myringotomy for 0-48 hours 1
  • Reassessment after 48 hours - if no improvement or clinical deterioration, surgical intervention should be considered 1, 6
  • Mastoidectomy is the standard surgical approach for complicated cases of otomastoiditis 1, 6
• Surgical intervention is indicated in:
  • Acute coalescent mastoiditis 6, 2
  • Evidence of intracranial complications 1, 6
  • Failure to respond to medical therapy within 48 hours 1, 6

Complications and Monitoring

• Brain abscess is the most common intracranial complication of otomastoiditis 1
• Other serious complications include:
  • Sigmoid sinus thrombosis 1
  • Meningitis 3
  • Subperiosteal abscess 7
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 1, 2
• CT scanning is essential if the patient fails to improve after 48 hours of IV antibiotics or if clinical deterioration occurs 1, 2

Special Considerations

• Chronic otomastoiditis may be influenced by healthcare accessibility and antibiotic resistance patterns 5
• Non-tuberculous mycobacterial otomastoiditis requires aggressive treatment to avoid morbidity 8
• Prior antibiotic treatment does not prevent the development of mastoiditis, with 33-81% of patients diagnosed with acute mastoiditis having received antibiotics before admission 1
• Treatment success rates vary:
  • Antibiotics alone: 10% success
  • Antibiotics plus myringotomy: 68% success
  • Antibiotics plus mastoidectomy: 22% success 1

Follow-up Care

• Once clinical improvement is noted, transition to oral antibiotics may be considered 4
• Persistent middle ear effusion is common after resolution of acute symptoms and should be monitored 4
• Regular follow-up is important to ensure complete resolution and to monitor for potential complications or recurrence 4