What is the recommended treatment for Otomastoiditis?

Treatment of Otomastoiditis

Immediate Management

Initiate intravenous broad-spectrum antibiotics immediately upon diagnosis of otomastoiditis, with consideration of myringotomy with or without tympanostomy tube insertion as first-line treatment. 1

Initial Antibiotic Therapy

• Start IV antibiotics without delay as soon as otomastoiditis is diagnosed 1
• For uncomplicated cases, use IV ceftriaxone at 50-75 mg/kg/day (not exceeding 2 grams daily) given once daily or in divided doses every 12 hours 2
• For complicated mastoiditis with suspected intracranial extension or severe disease, use vancomycin plus one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1
• If Streptococcus pyogenes is confirmed, add clindamycin to penicillin therapy 1

Pain Management

• Aggressive pain control is a critical component of care and should be addressed immediately 1

Surgical Decision Algorithm

0-48 Hours: Conservative Approach

• Begin with IV antibiotics with or without myringotomy 1
• Monitor closely for clinical response 1

48-Hour Reassessment Point

• If no improvement after 48 hours of IV antibiotics OR if clinical deterioration occurs at any point, obtain CT temporal bone with IV contrast 1
• CT provides high spatial resolution for assessing bony erosion and identifying complications such as subperiosteal abscess or coalescent mastoiditis 1

Surgical Intervention Criteria

• Myringotomy alone achieves success in 68% of cases when combined with antibiotics 1
• Mastoidectomy is required in 22% of cases and should be performed for: 1
  • Acute coalescent mastoiditis confirmed on CT
  • Intracranial complications
  • Failure to respond to antibiotics plus myringotomy within 48 hours 3

Imaging Strategy

When to Image

• Obtain imaging if patient fails to improve after 48 hours of IV antibiotics 1
• Image immediately if clinical deterioration occurs at any point 1
• Image if intracranial complications are suspected based on neurological signs 1

Imaging Modality Selection

• CT temporal bone with IV contrast is the primary modality for evaluating bony erosion, coalescence of air cells, and subperiosteal abscess 1, 4
• MRI without and with IV contrast has higher sensitivity and specificity than CT for detecting intracranial complications including brain abscess (the most common intracranial complication), subdural empyema, meningitis, or dural venous sinus thrombosis 1

Microbiology and Culture-Directed Therapy

Common Pathogens

• Streptococcus pneumoniae remains the most common pathogen (28.57% of culture-positive cases) 5, 6, 7, 3
• Streptococcus pyogenes causes more severe inflammation with higher rates of spontaneous tympanic membrane rupture and progression to acute mastoiditis 5
• Staphylococcus aureus and Pseudomonas aeruginosa are also frequently isolated 6, 7

Culture Guidance

• Obtain samples for bacterial culture prior to antibiotic treatment whenever possible, including under general anesthesia if necessary, due to the diversity of causative organisms and growing antibiotic resistance 7
• For patients failing initial therapy, adjust antibiotics based on culture results when available 1
• Consider clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis if cultures are unavailable 1

Transition to Oral Therapy

• Once clinical improvement is noted, transition to oral antibiotics may be considered 1
• Mean length of hospital stay is approximately 12.3 days 3

Monitoring for Complications

Intracranial Complications

• Monitor vigilantly for sigmoid sinus thrombosis, seizures, meningismus, neck rigidity, and neurological deficits 1
• Brain abscess is the most common intracranial complication 1
• Consider anticoagulation for sigmoid sinus thrombosis, though evidence is limited 1
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 1

Extracranial and Intratemporal Complications

• Watch for subperiosteal abscess, Bezold's abscess, facial nerve palsy, and labyrinthitis 6

Follow-Up Care

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

Critical Pitfalls to Avoid

• Prior antibiotic treatment does NOT prevent mastoiditis development: 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission 1, 7, 3
• Do not delay imaging in non-responding patients—failure to identify complications early can lead to life-threatening outcomes 1
• Antibiotics alone achieve success in only 10% of cases, so maintain a low threshold for myringotomy 1
• Do not use diluents containing calcium (such as Ringer's solution) with ceftriaxone due to precipitation risk 2