From the Guidelines
Mastoiditis should be treated with prompt medical attention, including intravenous antibiotics and possible surgical intervention with mastoidectomy, to prevent serious complications and improve outcomes. The treatment approach may vary depending on the severity of the infection and the presence of complications. According to the most recent and highest quality study 1, the traditional treatment of mastoiditis involved cortical mastoidectomy, but there is a recent trend toward nonsurgical management with intravenous antibiotics, either alone or combined with myringotomy and TT insertion and/or needle aspiration of the subperiosteal abscess.
Key Considerations
- Initial empiric therapy commonly includes intravenous antibiotics, such as ceftriaxone or vancomycin, which may be continued for 24-48 hours after clinical improvement, then switched to oral antibiotics like amoxicillin-clavulanate for a total of 2-3 weeks of therapy.
- Surgical intervention with mastoidectomy is often necessary for complicated cases or when medical therapy fails.
- Symptoms of mastoiditis include persistent ear pain, swelling behind the ear, fever, ear drainage, and hearing loss.
- Complications can be severe if left untreated, including meningitis, brain abscess, facial nerve paralysis, and hearing loss.
Diagnosis and Management
- Diagnosis typically involves physical examination, otoscopy, and imaging studies like CT scans to assess the extent of infection.
- The use of needle aspiration for subperiosteal abscess associated with acute mastoiditis has been reported, but most published literature reports surgical management 1.
- Patients should seek immediate medical attention if mastoiditis is suspected, as prompt treatment is essential to prevent serious complications.
Treatment Algorithm
- Chesney et al developed an algorithm whereby in uncomplicated AM cases (without neurologic deficits or sepsis), computerized tomography (CT) scanning is postponed and treatment is initiated with intravenous antibiotics, with or without myringotomy and/or drainage or aspiration of any subperiosteal abscess 1.
- Failure to improve after 48 hours or clinical deterioration should prompt a CT scan to assess coexistent intracranial pathology, followed by mastoidectomy.
From the Research
Definition and Clinical Findings
- Mastoiditis is a nonmeningeal complication of otitis media, characterized by fever, postauricular swelling, tenderness of the ear pinna, severe otalgia, and ear drainage 2.
- The condition is often associated with otitis media, and common bacteria include Streptococcus and Staphylococcus 3.
- Clinical findings may include tympanic membrane erythema, pinna protrusion, postauricular erythema, mastoid tenderness, external canal swelling, otorrhea, fever, and malaise 3.
Diagnosis and Management
- Diagnosis of mastoiditis should be suspected in patients who fail treatment for otitis media and those who demonstrate clinical abnormalities and systemic symptoms 3.
- Laboratory analysis may reveal evidence of systemic inflammation, but a normal white blood cell count and other inflammatory markers should not be used to exclude the diagnosis 3.
- Computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the clinician is unsure of the diagnosis 3.
- Treatment includes antibiotics such as ampicillin-sulbactam or ceftriaxone, as well as otolaryngology consultation 3.
- Surgical intervention, such as mastoidectomy, may be indicated if medical therapy fails or in cases of complicated mastoiditis 2, 4.
Complications and Treatment Outcomes
- Complications of mastoiditis may include subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures 3.
- Outpatient management of acute mastoiditis with periosteitis in children is possible with effective and safe parenteral antibiotic therapy, such as once daily i.m. ceftriaxone 5.
- The overall clinical cure rate for outpatient treatment of acute mastoiditis with periosteitis in children can be as high as 96.8% 5.
- The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media, and antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis 6.