What is the treatment for mastoiditis?

Treatment of Mastoiditis

Immediate Management

Start intravenous broad-spectrum antibiotics immediately upon diagnosis, with cloxacillin/flucloxacillin 50 mg/kg QDS (or 2g every 6 hours in adults) as first-line therapy for 10 days. 1

• Ceftriaxone 50-80 mg/kg daily IV serves as second-line therapy, particularly for penicillin-allergic patients 1
• Pain management is paramount and should be initiated concurrently with antibiotics 1, 2
• Consider myringotomy with or without tympanostomy tube insertion at presentation for drainage 1, 2

Bacteriology Considerations

• Streptococcus pneumoniae remains the most common causative organism despite PCV-13 vaccination 1, 3
• Other important pathogens include Streptococcus pyogenes, Staphylococcus aureus (increasingly prevalent at 16.32% in recent series), Haemophilus influenzae, and Pseudomonas aeruginosa 1, 4
• Cultures may be negative in 33-53% of cases, emphasizing the importance of empiric broad-spectrum coverage 1, 4

48-Hour Reassessment Algorithm

After 48 hours of IV antibiotics, reassess clinical status to determine need for surgical intervention. 1, 2

Indications for Surgery:

• No clinical improvement after 48 hours of IV antibiotics 1, 2, 5
• Clinical deterioration at any point 2
• Presence of subperiosteal abscess 1, 5
• Development of complications (intracranial extension, sigmoid sinus thrombosis) 1, 2
• Evidence of osteomyelitis beyond the mastoid framework 5

Surgical Options:

• Cortical mastoidectomy is the standard surgical approach for most cases requiring intervention 2, 5
• Modified radical mastoidectomy may be necessary for extensive disease 5
• Myringotomy alone may suffice in select cases without bony involvement 1, 6

Imaging Strategy

• Obtain CT scan of temporal bone with IV contrast if patient fails to improve after 48 hours or shows clinical deterioration 2, 5
• CT evaluates extent of disease, bony erosion, and identifies complications such as subperiosteal abscess 5
• MRI may be needed if intracranial complications are suspected, as brain abscess is the most common intracranial complication 2

Treatment Success Rates

The evidence demonstrates clear superiority of combined approaches:

• Antibiotics alone: 10% success rate 1, 2, 5
• Antibiotics plus myringotomy: 68% success rate 1, 2
• Antibiotics plus mastoidectomy: 22% success rate (reserved for complicated cases) 1, 2

These data support initial conservative management with antibiotics and myringotomy, reserving mastoidectomy for non-responders or complicated cases 6, 7

Antibiotic Duration and Transition

• Continue IV antibiotics for 7-10 days post-surgery if mastoidectomy performed 5
• For osteomyelitis, total antibiotic duration should be 4-6 weeks 5
• Transition to oral antibiotics once clinical improvement is noted, guided by culture results when available 2
• Consider clindamycin with or without coverage for H. influenzae and M. catarrhalis for treatment failures 2

Complicated Mastoiditis

For complicated mastoiditis with intracranial extension, broaden coverage to vancomycin plus one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole. 2

• For confirmed Streptococcus pyogenes, consider adding clindamycin to penicillin therapy 2
• Anticoagulation may be considered for sigmoid sinus thrombosis, though evidence is limited 2

Critical Pitfalls

• Prior antibiotic treatment does not prevent mastoiditis development, with 33-81% of patients having received antibiotics before admission 1, 2, 5, 4, 8
• Mastoiditis may be the first clinical sign of middle ear infection, especially in very young children under 3 years 8
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 2
• The incidence of mastoiditis has increased in recent years, with more complicated cases requiring surgical intervention 4, 7

Follow-up Care

• Monitor for persistent middle ear effusion after resolution of acute symptoms 2
• Perform hearing assessment if effusion persists for ≥3 months 2
• Regular follow-up ensures complete resolution and monitors for potential complications or recurrence 2
• Recurrent mastoiditis occurs in approximately 8% of patients 7