Treatment of Mastoiditis
The first-line treatment for mastoiditis is intravenous broad-spectrum antibiotics (specifically cloxacillin/flucloxacillin at 50 mg/kg QDS for children or 2g every 6 hours for adults), with surgical intervention indicated if there is no improvement after 48 hours of antibiotics, development of complications, or presence of subperiosteal abscess. 1
Diagnosis and Initial Assessment
- Mastoiditis is distinguished from uncomplicated acute otitis media by the presence of mastoid tenderness, retroauricular swelling, and protrusion of the auricle 1, 2
- High-resolution CT temporal bone with IV contrast is recommended to evaluate the extent of disease, bony erosion, and potential intracranial complications 3
- Prior antibiotic treatment does not eliminate the risk of developing mastoiditis, with 33-81% of patients diagnosed with mastoiditis having received antibiotics before admission 4, 1
Treatment Algorithm
Step 1: Immediate Antibiotic Therapy
- Start intravenous broad-spectrum antibiotics immediately upon diagnosis 1
- First-line: Cloxacillin/flucloxacillin (50 mg/kg QDS for children; 2g every 6 hours for adults) 1, 3
- Second-line (for penicillin allergy): Ceftriaxone IV (50-80 mg/kg daily) 1, 3
Step 2: Consider Initial Surgical Drainage
- Perform myringotomy with or without tympanostomy tube insertion to facilitate drainage 4, 1
- For subperiosteal abscess, consider needle aspiration or incision and drainage 4
Step 3: Reassessment After 48 Hours
- If clinical improvement occurs, continue IV antibiotics for 7-10 days, then transition to oral antibiotics based on culture results 3
- If no improvement or clinical deterioration occurs, proceed to imaging and consider surgical intervention 1, 3
Step 4: Surgical Management (if indicated)
- Indications for mastoidectomy include: 4, 1, 3
- No clinical improvement after 48 hours of IV antibiotics
- Development of complications (intracranial extension, facial nerve palsy)
- Presence of subperiosteal abscess
- Evidence of osteomyelitis
Treatment Success Rates
- Antibiotics alone: 10-24.6% success rate 4, 5
- Antibiotics plus myringotomy: 68% success rate 4
- Antibiotics plus mastoidectomy: 22-97% success rate 4, 5
Monitoring and Complications
- Monitor for potential complications including: 3, 2
- Sigmoid sinus thrombosis
- Intracranial extension (meningitis, brain abscess)
- Facial nerve palsy
- Labyrinthitis
- Signs of complications include headache, vertigo, meningismus, neck rigidity, seizures, or neurological deficits 2
Duration of Treatment
- Continue IV antibiotics for 7-10 days post-surgery 3
- Total antibiotic duration for cases with osteomyelitis: 4-6 weeks 3
Important Caveats
- Cultures from mastoid infections may be negative in up to 33-53% of cases, emphasizing the importance of clinical diagnosis 1, 2
- Streptococcus pneumoniae remains the most common causative organism, followed by Streptococcus pyogenes, Haemophilus influenzae, and Staphylococcus aureus 4, 6
- Mastoidectomy rates vary widely between 29-93% of patients with mastoiditis, reflecting differences in clinical practice rather than disease severity 4, 7