What is the treatment for mastoiditis?

Treatment of Mastoiditis

Initial Management: Immediate IV Antibiotics

Start intravenous cloxacillin/flucloxacillin at 50 mg/kg every 6 hours (QDS) for 10 days immediately upon diagnosis of mastoiditis. 1 For adults, the typical dose is 2g every 6 hours IV. 1 This represents the first-line antibiotic therapy recommended by the British Journal of Pharmacology for emergency department management. 1

Alternative First-Line Antibiotics

• Ceftriaxone serves as the second-line option at 50-80 mg/kg daily IV, particularly appropriate given that Streptococcus pneumoniae remains the most common causative organism despite PCV-13 vaccination. 1, 2
• For complicated mastoiditis requiring broader coverage, consider vancomycin plus one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole. 3
• High-dose IV amoxicillin-clavulanate at 80-90 mg/kg/day of the amoxicillin component (maximum 4000 mg/day) divided into 2-3 doses is another option for serious infections. 3

Pain Management

• Provide appropriate pain management as a critical component of care, though specific agents are not detailed in the guidelines. 3

The 48-Hour Decision Point

Reassess the patient after 48 hours of IV antibiotic therapy to determine if surgical intervention is needed. 1, 3 This represents the most critical juncture in mastoiditis management.

Indications for Surgical Intervention

Proceed to surgery if any of the following are present:

• No clinical improvement after 48 hours of IV antibiotics 1, 3
• Clinical deterioration at any point 3
• Development of complications (subperiosteal abscess, intracranial extension, facial nerve palsy, labyrinthitis) 1, 2
• Presence of subperiosteal abscess on examination or imaging 1

Surgical Options by Severity

• Myringotomy with or without tympanostomy tube insertion: Consider as initial surgical approach, particularly effective with success rates of 68% when combined with antibiotics. 1, 3
• Needle aspiration: May be attempted first for subperiosteal abscess before proceeding to more invasive procedures. 1
• Mastoidectomy: Standard surgical approach for complicated cases or failure of conservative management, with success rates of 97% in some series. 1, 4, 5

Imaging Strategy

Obtain CT temporal bone with IV contrast if the patient fails to improve after 48 hours or deteriorates at any point. 3 This provides high spatial resolution for assessing bony erosion, coalescence of air cells, and intratemporal complications. 6

• MRI without and with IV contrast should be obtained if intracranial complications are suspected (headache, vertigo, meningismus, neck rigidity, seizures, neurological deficits), as MRI has higher sensitivity and specificity than CT for detecting brain abscess, subdural empyema, meningitis, or dural venous sinus thrombosis. 3, 6

Treatment Success Rates by Modality

Understanding these success rates helps guide the treatment algorithm:

• Antibiotics alone: 10-24.6% success rate 1, 5
• Antibiotics plus myringotomy: 68-87.7% success rate 1, 5
• Antibiotics plus mastoidectomy: 22-97% success rate (wide variation reflects practice patterns and case selection) 1, 5

Transition to Oral Therapy

Once clinical improvement is noted, transition to oral antibiotics may be considered. 3 The specific oral regimen should be guided by culture results when available, with consideration of clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis for patients who fail initial therapy. 3

Monitoring for Complications

Vigilantly monitor for the following serious complications:

• Intracranial complications: Brain abscess (most common), subdural empyema, meningitis, sigmoid sinus thrombosis 3, 2
• Intratemporal complications: Facial nerve palsy, labyrinthitis 2
• Extracranial complications: Subperiosteal abscess, Bezold's abscess 2
• Seizures and other neurological deficits 1, 3

For sigmoid sinus thrombosis specifically, anticoagulation may be considered, though evidence is limited. 3

Common Pitfalls and Important Caveats

• Prior antibiotic treatment does NOT prevent mastoiditis: 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission. 1, 3, 6 Do not be falsely reassured by recent antibiotic use.
• Cultures may be negative: Mastoid infection cultures are negative in 33-53% of cases, emphasizing the importance of clinical diagnosis and empiric therapy. 1, 6
• No reliable clinical signs distinguish intracranial complications: Imaging is crucial in non-resolving cases, as physical examination alone cannot reliably exclude serious complications. 3
• Persistent middle ear effusion is common after resolution of acute symptoms and should be monitored with hearing assessment if effusion persists ≥3 months. 3

Follow-Up Care

• Regular follow-up is important to ensure complete resolution and monitor for potential complications or recurrence (8% recurrence rate in some series). 3, 4
• Hearing assessment should be performed if effusion persists for ≥3 months. 3

Special Bacteriologic Considerations

While Streptococcus pneumoniae remains the most common pathogen, other important organisms include:

• Streptococcus pyogenes (consider adding clindamycin to penicillin therapy for confirmed cases) 1, 3, 2
• Staphylococcus aureus 1, 2
• Haemophilus influenzae 1, 2
• Pseudomonas aeruginosa 1, 2
• Antibiotic-resistant or atypical pathogens such as Actinomyces spp. and Mycobacterium tuberculosis have been documented in some series. 7