Treatment of Mastoiditis
Immediate Initial Management
Start intravenous cloxacillin/flucloxacillin at 50 mg/kg every 6 hours (2g every 6 hours in adults) immediately upon diagnosis, and reassess after 48 hours to determine if surgical intervention is needed. 1, 2
- Ceftriaxone IV at 50-80 mg/kg daily serves as the second-line antibiotic option for patients with penicillin allergy 1, 2
- Pain management must be initiated concurrently with antibiotic therapy 1, 2
- The diagnosis requires clinical features beyond simple acute otitis media: mastoid tenderness, retroauricular swelling, and protrusion of the auricle 1
Critical 48-Hour Decision Point
After 48 hours of IV antibiotics, surgical intervention becomes necessary if there is no clinical improvement, development of complications, or presence of subperiosteal abscess. 1, 2
Surgical Options Based on Disease Severity:
- Myringotomy with or without tympanostomy tube insertion for drainage in less complicated cases 1, 2
- Cortical mastoidectomy as the standard surgical approach for complicated cases 2, 3
- Modified radical mastoidectomy may be required when extensive disease is present 3
The evidence shows treatment success rates vary dramatically: antibiotics alone achieve only 10% success, antibiotics plus myringotomy achieve 68% success, and antibiotics plus mastoidectomy achieve 22% success (reflecting selection of more severe cases for surgery) 1, 2
Imaging Strategy
Obtain CT temporal bone with IV contrast if the patient fails to improve or deteriorates after 48 hours, as this provides high spatial resolution for assessing bony erosion and intratemporal complications. 2
- MRI without and with IV contrast should be obtained if intracranial complications are suspected (brain abscess, subdural empyema, meningitis, or dural venous sinus thrombosis), as MRI has higher sensitivity and specificity than CT for these complications 2
- No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 2
Bacteriology and Antibiotic Adjustments
Streptococcus pneumoniae remains the most common causative organism despite PCV-13 vaccination, followed by Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa 1, 4
For Complicated Mastoiditis Requiring Broader Coverage:
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
- If initial therapy fails, antibiotic choices should be guided by culture results when available, with consideration of clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis 2
Duration of Therapy
Continue intravenous antibiotics for 7-10 days post-surgery if mastoidectomy is performed, then transition to oral antibiotics based on culture results. 3
- Total antibiotic duration for osteomyelitis involvement should be 4-6 weeks 3
- Once clinical improvement is noted in uncomplicated cases, transition to oral antibiotics may be considered 2
Complications Requiring Vigilant Monitoring
Monitor specifically for:
- Sigmoid sinus thrombosis (consider anticoagulation, though evidence is limited) 1, 2
- Brain abscess (the most common intracranial complication) 2
- Seizures, meningismus, neck rigidity, and neurological deficits 2
- Facial nerve palsy and labyrinthitis (intratemporal complications) 4
Critical Pitfalls to Avoid
Prior antibiotic treatment does not prevent the development of mastoiditis—33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission. 1, 2, 3
- Cultures from mastoid infections may be negative in 33-53% of cases, emphasizing the importance of clinical diagnosis rather than waiting for culture results 1
- Conservative management with antibiotics alone has only a 10% success rate, so maintain a low threshold for surgical intervention 1, 3
- Persistent middle ear effusion is common after resolution of acute symptoms and requires monitoring 2
Follow-Up Care
Hearing assessment should be performed if effusion persists for ≥3 months. 2