How should mastoiditis following acute otitis media be managed in children and adults?

Management of Mastoiditis

Start intravenous broad-spectrum antibiotics immediately upon diagnosis and perform myringotomy on the day of admission; if the patient fails to improve within 48–72 hours or develops complications, proceed to mastoidectomy. 1, 2

Initial Assessment and Immediate Management

Diagnostic Confirmation

• Diagnose mastoiditis based on acute onset of postauricular swelling, erythema, displaced pinna, and otalgia in the setting of acute otitis media or recent ear infection 3
• Obtain CT temporal bone with IV contrast if the patient fails to improve after 48 hours of IV antibiotics or if clinical deterioration occurs at any point, as this identifies bony erosion and intratemporal complications 1
• Consider MRI without and with IV contrast if intracranial complications are suspected (altered consciousness, seizures, focal neurological deficits, meningismus), as MRI has higher sensitivity than CT for detecting brain abscess, subdural empyema, or dural venous sinus thrombosis 1, 4

Immediate Interventions (Day of Admission)

• Initiate IV broad-spectrum antibiotics immediately—high-dose amoxicillin-clavulanate (80–90 mg/kg/day of amoxicillin component in children, maximum 4000 mg/day; 2000 mg twice daily in adults) divided into 2–3 doses 1, 5
• Perform myringotomy with or without tympanostomy tube insertion on the day of admission for all patients 1, 2
• Administer weight-based acetaminophen or ibuprofen immediately for pain control, as pain management is critical and should be initiated regardless of antibiotic therapy 1, 5

Antibiotic Selection Algorithm

First-Line IV Therapy

• Standard cases: High-dose IV amoxicillin-clavulanate (amoxicillin 80–90 mg/kg/day + clavulanate 6.4 mg/kg/day in 2–3 divided doses, maximum 4000 mg/day total) 1, 5
• Complicated mastoiditis (subperiosteal abscess, intracranial extension, or clinical deterioration): Vancomycin plus one of the following—piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1
• Confirmed Streptococcus pyogenes: Add clindamycin to penicillin therapy 1

Treatment Failure Protocol

• If the patient fails initial amoxicillin-clavulanate after 48–72 hours, switch to intramuscular ceftriaxone 50 mg/kg/day for 1–3 days (3-day course superior to 1-day regimen) 1, 5
• Guide subsequent antibiotic choices by culture results when available; consider clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis 1

Transition to Oral Antibiotics

• Once clinical improvement is noted (typically after 7–10 days of IV therapy), transition to high-dose oral amoxicillin-clavulanate (80–90 mg/kg/day of amoxicillin component divided twice daily in children, maximum 4000 mg/day; 2000 mg twice daily in adults) 1
• Penicillin-allergic patients (non-immediate hypersensitivity): Use cefdinir, cefpodoxime proxetil, or cefuroxime axetil 1
• Immediate Type I hypersensitivity: Use clindamycin plus an agent covering H. influenzae and M. catarrhalis such as cefixime or cefdinir 1
• Avoid macrolides (azithromycin, clarithromycin) and trimethoprim-sulfamethoxazole due to high failure rates (20–25%) from pneumococcal resistance 1
• Reassess within 48–72 hours of switching to oral therapy to ensure continued improvement 1

Surgical Intervention Algorithm

Initial Conservative Approach (0–48 Hours)

• All patients receive IV antibiotics plus myringotomy on admission 1, 2
• Subperiosteal abscess present at admission: Perform drainage or simple mastoidectomy immediately 2
• Intracranial complications present at admission: Perform simple mastoidectomy immediately 2

Indications for Mastoidectomy

• Failure to improve after 48–72 hours of appropriate IV antibiotics and myringotomy 1, 5, 2
• Development of subperiosteal abscess during treatment 1, 5
• Presence of cholesteatoma 5
• Intracranial complications (brain abscess, sigmoid sinus thrombosis, meningitis, subdural empyema) 1, 5, 4
• Clinical deterioration at any point 1, 5

Surgical Technique

• Simple mastoidectomy is the standard procedure for acute mastoiditis 1, 2
• Modified radical mastoidectomy is required when cholesteatoma is identified or subperiosteal abscess drainage fails 5
• Continue IV antibiotics for 7–10 days postoperatively, then transition to oral antibiotics based on culture results 5

Expected Treatment Outcomes

Success Rates by Treatment Modality

• Antibiotics alone: 10% success rate 1, 5
• Antibiotics plus myringotomy: 68% success rate 1
• Antibiotics plus mastoidectomy: 22% of cases require this approach 1
• Overall cure rate with algorithmic approach: 100% with mean hospitalization of 9.8 days 2

Post-Treatment Monitoring

• Persistent middle ear effusion occurs in 60–70% of patients at 2 weeks, decreasing to 40% at 1 month and 10–25% at 3 months—this does not require additional antibiotics unless symptomatic 1, 5
• Perform age-appropriate hearing testing if middle ear effusion persists ≥3 months after resolution of acute symptoms 1, 5
• Regular follow-up is essential to ensure complete resolution and monitor for recurrence 1, 5

Critical Pitfalls and Complications

Common Mistakes to Avoid

• Do not delay imaging if clinical deterioration occurs, as no reliable clinical signs distinguish patients with coexistent intracranial complications 1, 5
• Do not rely on prior antibiotic treatment to prevent mastoiditis—33–81% of patients diagnosed with acute mastoiditis had received antibiotics before admission 6, 1, 5, 7
• Do not use macrolides or trimethoprim-sulfamethoxazole as step-down therapy due to substantial pneumococcal resistance 1
• Do not delay mastoidectomy beyond 3–5 days in non-responsive cases to avoid further in-hospital acquired complications 2

Intracranial Complications (6.5–10% of Cases)

• Brain abscess is the most common intracranial complication 1, 3
• Sigmoid sinus thrombosis requires consideration of anticoagulation (though evidence is limited) and may necessitate thrombectomy and jugular vein ligation 1, 4
• Meningitis and subdural empyema require immediate neurosurgical consultation 1, 4
• Monitor vigilantly for seizures, altered consciousness, nuchal rigidity, and focal neurological deficits 1, 4
• Increased mortality correlates with neurological status on admission 4

Age-Specific Considerations

• Children under 5 years are at highest risk for mastoiditis despite antibiotic use 3
• Streptococcus pneumoniae remains the most common pathogen (38.7% of cases), followed by Pseudomonas aeruginosa (6.4%) 8, 3