What is the treatment for mastoiditis?

Treatment of Mastoiditis

The treatment of mastoiditis requires prompt initiation of intravenous broad-spectrum antibiotics as first-line therapy, with consideration of myringotomy with or without tympanostomy tube insertion, and progression to mastoidectomy if there is no improvement after 48 hours of medical therapy or if complications develop. 1

Initial Management

• Begin with intravenous broad-spectrum antibiotics immediately upon diagnosis of mastoiditis 1, 2
• Consider myringotomy with or without tympanostomy tube placement to provide drainage and obtain cultures 1, 2
• Pain management is a critical component of care 1
• High-dose amoxicillin-clavulanate is an alternative option for antibiotic regimens in select cases 2

Treatment Algorithm

1. First 48 hours: Intravenous antibiotics with or without myringotomy 1

   • Monitor closely for clinical improvement during this period 2
   • Obtain cultures when possible to guide antibiotic selection 1

2. After 48 hours:

   • If improvement is seen: Continue current therapy 1
   • If no improvement or clinical deterioration: Obtain CT imaging and consider surgical intervention 1, 2

3. Surgical intervention indications:

   • Failure to improve after 48 hours of appropriate IV antibiotics 1, 2
   • Presence of subperiosteal abscess (some may be managed with needle aspiration) 2
   • Evidence of intracranial complications 1, 2

Antibiotic Selection

• For empiric therapy, coverage should include common pathogens such as Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, and Staphylococcus aureus 3
• For complicated mastoiditis, broader coverage is recommended, including vancomycin plus one of: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1
• Once clinical improvement is noted, transition to oral antibiotics may be considered 1

Imaging

• CT scanning of the temporal bone with IV contrast is recommended if the patient fails to improve after 48 hours of IV antibiotics, or if there is clinical deterioration 1, 2
• MRI with contrast is superior to CT for evaluation of intracranial complications 2

Treatment Success Rates

• Treatment success rates vary significantly by approach 1:
  • Antibiotics alone: 10-24.6% success rate 1, 4
  • Antibiotics plus myringotomy or other minor surgical procedures: 68-87.7% success rate 1, 4
  • Antibiotics plus mastoidectomy: 97% success rate 4

Management of Complications

• Brain abscess is the most common intracranial complication of mastoiditis 1
• Other complications include sigmoid sinus thrombosis, meningitis, and facial nerve palsy 1, 5
• Anticoagulation may be considered for sigmoid sinus thrombosis in the absence of contraindications 1, 2
• For intracranial complications, surgical intervention is typically required in addition to antibiotics 1

Follow-up Care

• Regular follow-up is important to ensure complete resolution 1
• Hearing assessment should be performed if effusion persists for ≥3 months 1
• Persistent middle ear effusion is common after resolution of acute symptoms and should be monitored 1

Common Pitfalls and 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 1, 2
• Cultures from mastoid infections may be negative in up to 33-53% of cases, emphasizing the importance of broad-spectrum empiric coverage 2, 5
• The incidence of mastoiditis complications has been increasing in some regions, with more cases requiring surgical intervention 6
• Delaying appropriate treatment can lead to increased morbidity and potentially life-threatening complications 1