What is the treatment for a pediatric or adult patient with a history of ear infections diagnosed with otomastoiditis?

Treatment of Otomastoiditis

Otomastoiditis requires immediate initiation of intravenous broad-spectrum antibiotics combined with myringotomy (with or without tympanostomy tube insertion), with mastoidectomy reserved for patients who fail to improve within 48 hours or who present with complications. 1

Initial Management Algorithm

Immediate Actions Upon Diagnosis

• Start IV antibiotics immediately upon clinical diagnosis of otomastoiditis, which presents with retroauricular inflammation, postauricular edema, fever, otalgia, and an abnormal tympanic membrane 1, 2, 3
• Perform myringotomy with or without tympanostomy tube placement as part of initial conservative management 1
• Provide aggressive pain management as a critical component of care, using acetaminophen or ibuprofen 1, 4

Antibiotic Selection

For initial empiric IV therapy, use one of the following regimens:

• IV amoxicillin-clavulanate at 80-90 mg/kg/day of the amoxicillin component (maximum 4000 mg/day), divided into 2-3 doses for pediatric patients 1, 5
• For adults: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours for severe infections 5

For complicated mastoiditis or treatment failures, broader coverage is required 1:

• Vancomycin PLUS one of: piperacillin-tazobactam, carbapenem, ceftriaxone plus metronidazole, or fluoroquinolone plus metronidazole 1
• If Streptococcus pyogenes is confirmed, add clindamycin to penicillin therapy 1

Critical 48-Hour Decision Point

Reassess at 48-72 hours and proceed based on clinical response 1, 2:

• If improving: Continue IV antibiotics, consider transition to oral antibiotics once clinical improvement is noted 1
• If no improvement or deterioration:
  • Obtain CT temporal bone with IV contrast to assess for bony erosion, subperiosteal abscess, or intratemporal complications 1
  • Proceed to mastoidectomy 1, 2

Surgical Intervention Criteria

Mastoidectomy is indicated for 1, 2:

• Failure to improve after 48 hours of IV antibiotics and myringotomy
• Acute coalescent mastoiditis on imaging
• Subperiosteal abscess formation
• Any intracranial complications (brain abscess, sigmoid sinus thrombosis, meningitis)

Imaging Strategy

• CT temporal bone with IV contrast if patient fails to improve or deteriorates, providing high spatial resolution for bony erosion assessment 1
• MRI without and with IV contrast if intracranial complications are suspected (brain abscess, subdural empyema, meningitis, dural venous sinus thrombosis), as MRI has higher sensitivity than CT for these complications 1

Microbiology and Culture-Directed Therapy

Common pathogens include Streptococcus pneumoniae (most common), Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis 6, 2, 3

• For treatment failures, antibiotic choices should be guided by culture results when available 1
• Consider clindamycin with or without coverage for H. influenzae and M. catarrhalis for culture-negative cases 1
• Note: 53-80% of cases may have negative cultures despite prior antibiotic therapy 6, 2

Treatment Success Rates and Expected Outcomes

• Antibiotics alone: 10% success rate 1
• Antibiotics plus myringotomy: 68% success rate 1
• Antibiotics plus mastoidectomy: 22% require this approach 1
• Mean hospital stay: 7.9-12.3 days 2, 3

Critical Pitfalls to Avoid

• Prior antibiotic treatment does NOT prevent mastoiditis development: 33-81% of patients with acute mastoiditis had received antibiotics before admission 1, 6, 2
• Do NOT delay imaging if clinical deterioration occurs at any point—intracranial complications can develop rapidly 1
• No reliable clinical signs distinguish patients with coexistent intracranial complications, making imaging crucial in non-resolving cases 1
• Avoid using topical antibiotics for otomastoiditis—these are contraindicated and only indicated for tube otorrhea or otitis externa 4

Special Consideration: Refractory Cases

If otomastoiditis is refractory to standard therapy (persistent otorrhea despite appropriate antibiotics and surgery):

• Suspect atypical pathogens, particularly nontuberculous mycobacteria (NTM) or tuberculous mycobacteria 7, 8
• NTM otomastoiditis presents with chronic refractory otorrhea, granulation tissue (90.9%), and soft tissue attenuation in middle ear cavities on imaging 7
• Treatment for NTM: Surgery (mainstay) complemented with antimycobacterial antibiotics; in patients without temporal bone osteomyelitis, antibiotics can be stopped after achieving a dry ear 7

Post-Treatment Follow-Up

• 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

Transition to Oral Therapy

• Once clinical improvement is noted, transition to oral antibiotics may be considered 1
• Continue monitoring for complete resolution of symptoms and signs