What is the recommended treatment for otomastoiditis?

Treatment of Otomastoiditis

Initiate intravenous broad-spectrum antibiotics immediately upon diagnosis, with myringotomy considered as an adjunct, and proceed to mastoidectomy if no improvement occurs within 48 hours or if complications develop. 1

Initial Antibiotic Therapy

Start IV antibiotics without delay as the cornerstone of treatment for acute otomastoiditis. 1 The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that prompt antimicrobial therapy is critical to prevent intracranial complications. 1

First-Line IV Antibiotic Regimens:

• For uncomplicated cases: Administer IV amoxicillin-clavulanate at 80-90 mg/kg/day of the amoxicillin component (maximum 4000 mg/day), divided into 2-3 doses. 1 A practical regimen is 1333 mg IV every 8 hours or 2000 mg IV every 12 hours. 1

• For complicated mastoiditis with suspected intracranial extension: Use vancomycin PLUS one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole. 1 This broader coverage addresses the polymicrobial nature of complicated disease and provides anti-staphylococcal coverage. 2

• For confirmed Streptococcus pyogenes: Add clindamycin to penicillin therapy. 1

The rationale for aggressive initial therapy stems from the pathogen distribution: Streptococcus pneumoniae causes 38.7% of cases, but Staphylococcus aureus and Pseudomonas aeruginosa (6.4%) are also significant pathogens. 1, 3, 2

Surgical Adjuncts

Myringotomy with or without Tympanostomy Tube

• Perform myringotomy early (within 0-48 hours) to facilitate drainage and obtain culture material. 1, 4 This procedure complements antibiotic therapy and improves outcomes, with antibiotics plus myringotomy achieving 68% success rates compared to only 10% for antibiotics alone. 1

Mastoidectomy Indications

Proceed to mastoidectomy if:

• No clinical improvement after 48 hours of appropriate IV antibiotics 1
• Clinical deterioration at any point 1
• Subperiosteal abscess present 1
• Intracranial complications identified 1

Mastoidectomy is required in 22% of cases and represents definitive treatment for complicated disease. 1 The American Academy of Otolaryngology-Head and Neck Surgery recommends urgent otolaryngology consultation when these criteria are met. 1

Imaging Protocol

• Obtain CT temporal bone with IV contrast if the patient fails to improve after 48 hours of IV antibiotics or shows any clinical deterioration. 1, 5 High-resolution CT provides optimal assessment of 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). 1, 5 MRI has superior sensitivity for detecting brain abscess, subdural empyema, meningitis, or sigmoid sinus thrombosis. 1

Brain abscess is the most common intracranial complication, and no reliable clinical signs distinguish patients with coexistent intracranial involvement, making imaging crucial in non-resolving cases. 1

Transition to Oral Therapy

Once clinical improvement is documented (typically after 48-72 hours of IV therapy), transition to oral antibiotics: 1

Preferred Oral Regimen:

• High-dose amoxicillin-clavulanate: 80-90 mg/kg/day of amoxicillin component divided twice daily (maximum 4000 mg/day) for children; 2000 mg twice daily for adults. 1

Alternative Regimens for β-Lactam Allergy:

• Non-immediate hypersensitivity: Cefdinir, cefpodoxime proxetil, or cefuroxime axetil 1
• Immediate Type I hypersensitivity: Clindamycin PLUS cefixime or cefdinir (for H. influenzae and M. catarrhalis coverage) 1

Avoid macrolides (azithromycin, clarithromycin) and trimethoprim-sulfamethoxazole due to 20-25% failure rates from pneumococcal resistance. 1

Duration of Therapy

• Total antibiotic duration: Continue until complete clinical resolution is achieved. 1 For standard cases without osteomyelitis, treatment can be stopped once the ear is dry and symptoms have resolved. 6

• Reassess within 48-72 hours of switching to oral therapy to ensure continued improvement. 1

Pain Management

• NSAIDs (ibuprofen, naproxen) are first-line for mild-to-moderate pain 5
• Opioids (oxycodone, hydrocodone) reserved for moderate-to-severe pain 5

Follow-Up and Monitoring

• Persistent middle ear effusion is expected: 60-70% of children have effusion at 2 weeks, decreasing to 10-25% at 3 months. 1 This does not require continued antibiotics unless symptomatic. 1

• Perform hearing assessment if effusion persists ≥3 months. 1

• Monitor for complications: Sigmoid sinus thrombosis, meningitis, subdural empyema, facial nerve palsy, and labyrinthitis. 1, 3 Children with mastoiditis are at particularly high risk for venous sinus thrombosis. 1

Critical Pitfalls to Avoid

• Prior antibiotic treatment does not prevent mastoiditis: 33-81% of patients diagnosed with acute mastoiditis had received antibiotics before admission. 1 Do not assume prior treatment provides protection.

• Do not delay imaging in non-resolving cases: Intracranial complications can be clinically occult and require CT or MRI for detection. 1

• Ensure adequate bone-penetrating antibiotics: When mastoid involvement is confirmed, systemic antibiotics with bone penetration are mandatory—topical therapy alone is insufficient. 5

• Consider anticoagulation for sigmoid sinus thrombosis, though evidence is limited. 1

• In diabetic or immunocompromised patients: Maintain tight glycemic control and consider broader coverage for fungal superinfection and atypical organisms including nontuberculous mycobacteria in refractory cases. 5, 6