What is the management for chronic mastoiditis?

Management of Chronic Mastoiditis

Chronic mastoiditis requires surgical intervention (mastoidectomy) as the definitive treatment, combined with prolonged intravenous broad-spectrum antibiotics, as medical therapy alone has limited success in eradicating established chronic infection with or without cholesteatoma. 1, 2

Initial Assessment and Antibiotic Therapy

• Start intravenous broad-spectrum antibiotics immediately upon diagnosis, with recommended regimens including IV amoxicillin-clavulanate at 80-90 mg/kg/day (maximum 4000 mg/day) for serious infection 3, 4
• For complicated cases or treatment failures, broaden coverage to include vancomycin plus either piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 4
• Consider adding clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis if initial therapy fails 4
• Obtain cultures to guide antibiotic selection when possible 4, 1

Imaging Requirements

• Obtain CT temporal bone with IV contrast to assess the extent of bony erosion, evaluate for cholesteatoma, and identify intratemporal complications 3, 4
• Consider MRI without and with IV contrast 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 4

Surgical Management

Mastoidectomy is the standard surgical approach for chronic mastoiditis, particularly when cholesteatoma is present or when medical management fails 4, 1, 2

• The choice between "canal wall up" versus "canal wall down" mastoidectomy depends on the extent of pathology in relation to mastoid size 2
• Early diagnosis and adequate surgical treatment combined with effective antibiotic therapy is essential to prevent serious extracranial and intracranial complications 1
• Surgical success rates for mastoidectomy approach 97%, significantly higher than conservative approaches 5

Surgical Timing Algorithm:

1. Immediate surgery indicated for:

   • Presence of cholesteatoma 2
   • Intracranial complications (brain abscess, sigmoid sinus thrombosis, meningitis) 4, 1
   • Subperiosteal abscess requiring drainage 5
   • Clinical deterioration despite 48 hours of IV antibiotics 3, 4

2. Consider surgery after failed medical management:

   • No improvement after 48 hours of appropriate IV antibiotics 3, 4
   • Recurrent episodes despite adequate medical therapy 1

Pain Management

• Assess pain severity using validated scales 3
• Use acetaminophen or NSAIDs for mild-moderate pain 3
• Consider opioid combinations for severe pain 3

Monitoring for Complications

Monitor vigilantly for:

• Sigmoid sinus thrombosis 4
• Seizures, meningismus, neck rigidity 4
• Neurological deficits 4
• Brain abscess (the most common intracranial complication) 4

Consider anticoagulation for sigmoid sinus thrombosis, though evidence is limited 4

Transition to Oral Therapy and Follow-up

• Once clinical improvement is noted, transition to oral antibiotics may be considered 4
• Persistent middle ear effusion is common after resolution of acute symptoms and requires monitoring 4
• Perform hearing assessment if effusion persists for ≥3 months 4
• Regular follow-up is essential to ensure complete resolution and monitor for recurrence or residual cholesteatoma 4, 2

Critical Pitfalls to Avoid

• Do not rely on antibiotics alone for chronic mastoiditis—success rates are only 24.6% with medical therapy alone versus 97% with mastoidectomy 5
• Prior antibiotic treatment does not prevent progression, as 33-81% of patients with acute mastoiditis had received antibiotics before admission 4
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 4
• Cholesteatoma requires surgical removal and cannot be adequately treated with antibiotics alone 2