From the Guidelines
Malignant mastoiditis in a patient with diabetes mellitus (DM) should be treated with intravenous antibiotics, potentially combined with myringotomy and mastoidectomy if necessary, as the patient's compromised immune status due to DM increases the risk of complications.
Treatment Approach
- The treatment approach for malignant mastoiditis involves aggressive antibiotic therapy, with the goal of covering common pathogens such as Streptococcus pneumoniae 1.
- Intravenous antibiotics should be initiated promptly, with consideration of the patient's recent antibiotic use and potential resistance patterns.
- Myringotomy and tube thoracostomy (TT) insertion may be necessary to drain the middle ear and relieve pressure, especially if there is evidence of a subperiosteal abscess.
- Mastoidectomy may be required in cases of complicated mastoiditis, such as those with neurologic deficits, sepsis, or failure to improve with initial treatment, as suggested by Chesney et al's algorithm 1.
Antibiotic Selection
- The choice of antibiotic should be guided by local resistance patterns and the patient's individual risk factors, such as recent antibiotic use.
- High-dose amoxicillin or amoxicillin-clavulanic acid may be considered as first-line therapy, with adjustments made based on culture and sensitivity results 1.
Management Considerations
- Patients with DM require close monitoring due to their increased risk of complications, such as abscess formation and neurologic deficits.
- Regular assessment of the patient's clinical status, including imaging studies such as CT scans, should be performed to guide treatment decisions and detect potential complications early 1.
From the Research
Treatment for Malignant Mastoiditis in Patients with Diabetes Mellitus
The treatment for malignant mastoiditis in patients with diabetes mellitus (DM) typically involves aggressive antibiotic therapy and, in some cases, surgical intervention.
- The mainstay of treatment is the administration of antipseudomonal antibiotics for four to eight weeks 2.
- Surgery may be necessary to debride granulation tissue in the mastoid bowl, as seen in a case where a 63-year-old diabetic male developed malignant otitis externa following mastoidectomy 3.
- In cases where mastoiditis is complicated by other conditions, such as dural sinus thrombosis or Bezold's abscess, timely and aggressive treatment is crucial to mitigate complications 4.
- The use of new diagnostic radiologic modalities and new antipseudomonal antibiotics may lead to improved outcomes 2.
- In some cases, treatment with a flow diverter may be necessary to occlude carotid pseudoaneurysms that develop as a complication of malignant otitis externa 5.
Important Considerations
- Malignant mastoiditis is a serious condition that can result in significant morbidity and mortality, particularly in patients with diabetes mellitus 2.
- Early recognition and treatment of the condition are critical to preventing complications and improving outcomes 4, 2.
- The role of surgery should be minimized, and used only when necessary to debride granulation tissue or treat complications 2.