What is the treatment for mastoiditis in children?

Treatment of Mastoiditis in Children

Mastoiditis in children requires immediate intravenous broad-spectrum antibiotics as first-line treatment, with cloxacillin/flucloxacillin (50 mg/kg QDS for 10 days) or ceftriaxone as the preferred initial agents, combined with myringotomy for drainage in most cases. 1, 2

Initial Management Algorithm

Immediate Actions Upon Diagnosis

• Start IV antibiotics immediately without waiting for culture results, as cultures are negative in 33-53% of cases 1, 2
• First-line antibiotic: Cloxacillin/flucloxacillin 50 mg/kg IV every 6 hours (QDS) for 10 days 2
• Second-line antibiotic: Ceftriaxone 50-80 mg/kg IV daily if penicillin allergy or treatment failure 2
• Alternative regimen: IV amoxicillin-clavulanate at 80-90 mg/kg/day of the amoxicillin component (maximum 4000 mg/day), divided into doses of 1333 mg every 8 hours or 2000 mg every 12 hours 1
• Consider myringotomy with or without tympanostomy tube insertion for drainage at presentation 1, 3
• Provide appropriate pain management as a critical component of care 1

Rationale for Antibiotic Selection

The choice of cloxacillin/flucloxacillin or ceftriaxone is based on the predominant pathogens: Streptococcus pneumoniae remains the most common organism (despite PCV-13 vaccination), followed by Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa 2, 4, 5

48-Hour Reassessment Protocol

Clinical Decision Point at 48 Hours

Reassess the patient after 48 hours of IV antibiotics to determine if escalation is needed 1, 2, 6

Proceed to imaging and surgical consultation if:

• No clinical improvement after 48 hours of IV antibiotics 1, 2, 6
• Clinical deterioration at any point 1
• Development of complications (subperiosteal abscess, intracranial extension, facial nerve palsy) 1, 6, 4
• Persistent fever or elevated inflammatory markers 6

Imaging Recommendations

• CT scan of temporal bone with IV contrast if patient fails to improve after 48 hours or shows clinical deterioration 1, 6
• MRI may be needed if intracranial complications are suspected 6

Surgical Management

Indications for Surgery

Surgical intervention is indicated when:

• No improvement after 48 hours of IV antibiotics and myringotomy 1, 2, 3
• Presence of subperiosteal abscess 1, 2, 6
• Evidence of osteomyelitis beyond the mastoid framework 6
• Development of intracranial complications 1, 6

Surgical Options

• Myringotomy with or without tympanostomy tube: Initial drainage procedure, often combined with antibiotics 1, 3, 7
• Cortical mastoidectomy: For cases not responding to conservative management 1, 6
• Modified radical mastoidectomy: For extensive disease with osteomyelitis 6

Treatment Success Rates

The evidence shows clear superiority of combined approaches: antibiotics alone achieve only 10% success, antibiotics plus myringotomy achieve 68% success, and antibiotics plus mastoidectomy achieve 22% success (the latter for more complicated cases) 1, 2, 6

Antibiotic Therapy for Complicated Cases

Broader Coverage for Severe Disease

For complicated mastoiditis with intracranial extension or severe disease:

• Vancomycin PLUS one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1
• For confirmed Streptococcus pyogenes: Add clindamycin to penicillin therapy 1

Duration of Antibiotic Therapy

• IV antibiotics: Continue for 7-10 days post-surgery if surgical intervention was performed 6
• Total duration for osteomyelitis: 4-6 weeks of antibiotics (transition to oral based on culture results and clinical improvement) 6
• Transition to oral antibiotics: Once clinical improvement is noted, guided by culture results when available; consider clindamycin with or without coverage for H. influenzae and M. catarrhalis 1

Outpatient Management Considerations

Selected cases of uncomplicated mastoiditis with periosteitis can be managed as outpatients with once-daily IM ceftriaxone after initial assessment, provided there is daily follow-up by a combined team of otolaryngology and infectious disease specialists 7. This approach achieved a 96.8% clinical cure rate in one study, though most guidelines recommend initial hospitalization for IV antibiotics 7.

Follow-Up and Monitoring

Post-Treatment Surveillance

• Persistent middle ear effusion is common after resolution of acute symptoms and requires monitoring 1
• Hearing assessment should be performed if effusion persists for ≥3 months 1
• Regular follow-up is essential to ensure complete resolution and monitor for recurrence or complications 1

Complications to Monitor

• Extracranial: Subperiosteal abscess, Bezold's abscess 4
• Intratemporal: Facial nerve palsy, labyrinthitis 4
• Intracranial: Brain abscess (most common intracranial complication), subdural abscess, sigmoid sinus thrombosis, seizures 1, 2, 4
• Consider anticoagulation for sigmoid sinus thrombosis, though evidence is limited 1

Critical Pitfalls and Caveats

Common Misconceptions

• Prior antibiotic treatment does NOT prevent mastoiditis: 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission 1, 2, 6
• No reliable clinical signs distinguish patients with intracranial complications, making imaging crucial in non-resolving cases 1
• Culture negativity is common (33-53% of cases), emphasizing the importance of empiric therapy and clinical diagnosis 2

Key Clinical Features

Distinguishing features of mastoiditis versus uncomplicated acute otitis media include: mastoid tenderness, retroauricular swelling and erythema, and protrusion of the auricle 2, 3. All four signs (post-auricular erythema, edema, tenderness, and protrusion) are present in only 40.9% of patients 3.

Risk Factors for Severe Disease

Young age (often <2 years), high fever, and markedly elevated inflammatory markers (very high WBC count, absolute neutrophil count, and C-reactive protein) are associated with more severe disease and complications 4.