What is the treatment for mastoiditis?

Treatment of Mastoiditis

Mastoiditis requires immediate intravenous broad-spectrum antibiotics with myringotomy and tympanostomy tube placement, and surgical mastoidectomy is indicated for patients who fail to improve after 48 hours of medical therapy or who present with complications such as subperiosteal abscess or intracranial extension. 1

Initial Medical Management

• Start IV broad-spectrum antibiotics immediately upon diagnosis, with high-dose amoxicillin-clavulanate or cephalosporins as first-line agents given the predominance of Streptococcus pneumoniae as the causative pathogen 1, 2
• Perform myringotomy with or without tympanostomy tube placement to provide drainage and obtain cultures for targeted antibiotic therapy 1
• Obtain cultures from the middle ear and mastoid, though be aware that 33-53% of mastoid infections may have negative cultures 1, 3
• Monitor closely for clinical improvement during the first 48 hours of treatment 1

Indications for Surgical Intervention

Proceed to mastoidectomy if:

• No clinical improvement after 48 hours of appropriate IV antibiotic therapy 1
• Presence of subperiosteal abscess on clinical examination or imaging 1
• Evidence of intracranial complications (meningitis, brain abscess, subdural empyema, dural venous sinus thrombosis) 1, 3
• Presence of cholesteatoma, which necessitates surgical intervention rather than medical management alone 4
• Clinical deterioration despite medical therapy 5

Surgical Approach

• Mastoidectomy is the definitive surgical treatment, with the specific technique (simple vs. modified radical) determined by the extent of disease 4
• For subperiosteal abscesses exceeding 20 mm in mean size, consider incision and drainage along with myringotomy and tube placement as initial treatment 5
• Closed mastoidectomy should be reserved for deteriorating clinical evolution or acute mastoiditis with intracranial complications 5
• Neurosurgical intervention (craniotomy with mastoidectomy) may be necessary for intracranial complications in approximately 19% of cases with such complications 5

Imaging Requirements

• Obtain high-resolution CT of the temporal bone with IV contrast to evaluate bone destruction, coalescence of air cells, and associated soft tissue complications 3
• MRI with contrast is superior to CT for evaluating intracranial complications and should be obtained when intracranial extension is suspected 1, 3

Anticoagulation Considerations

• Consider anticoagulation for sigmoid sinus thrombosis in the absence of contraindications 1

Important Clinical Caveats

• Prior antibiotic treatment does not prevent mastoiditis development, as 33-81% of mastoiditis cases had received antibiotics previously for acute otitis media 1, 3
• The success rate of conservative management with antibiotics alone is only 10%, while antibiotics plus mastoidectomy has a 22% success rate in acute mastoiditis 4
• Staphylococcus aureus is increasingly isolated (16% of cases), in addition to S. pneumoniae (29%), requiring broad-spectrum coverage 6
• Elevated white blood cell count, proptosis of the auricle, and fever on admission are risk factors for requiring surgical intervention 7
• Intracranial and multiple concomitant complications are associated with longer hospital stays, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae 5
• Permanent hearing loss occurs in approximately 2.7% of cases, more commonly with intratemporal complications 5

Duration of Therapy

• Continue IV antibiotics for 7-10 days, then transition to oral antibiotics based on culture results and clinical response 4
• Average hospital stay is approximately 7.9 days, with longer stays required for surgical cases 7