Management of Mastoiditis

Initial Assessment and Management

The British Journal of Pharmacology recommends the first-line treatment for mastoiditis in the emergency department is intravenous broad-spectrum antibiotics, specifically cloxacillin/flucloxacillin at a dose of 50 mg/kg QDS for 10 days, with ceftriaxone as a second-line option 1, 2
Key clinical features distinguishing mastoiditis from uncomplicated acute otitis media include mastoid tenderness, retroauricular swelling, and protrusion of the auricle 3

The recommended first-line antibiotic therapy is cloxacillin/flucloxacillin IV at 50 mg/kg QDS for 10 days 1
For adults, typical dosing of cloxacillin/flucloxacillin is 2g every 6 hours IV 4
Second-line antibiotic therapy is ceftriaxone IV at 50-80 mg/kg daily 1

Initiate antibiotics immediately upon diagnosis, and reassess after 48 hours of IV antibiotics 2
Consider surgical intervention if there is no clinical improvement after 48 hours of IV antibiotics, development of complications, or presence of subperiosteal abscess 2
Surgical options include myringotomy with or without tympanostomy tube insertion, and mastoidectomy for complicated cases 2

Start IV cloxacillin/flucloxacillin, and consider myringotomy for drainage 1, 2
Provide appropriate pain management, and reassess at 48 hours 2
If not improving or worsening, obtain CT scan and consider surgical intervention 2

Sigmoid sinus thrombosis and seizures are potential complications of mastoiditis 2

Prior antibiotic treatment does not prevent the development of mastoiditis, with 33-81% of patients diagnosed with acute mastoiditis having received antibiotics before admission 2
Cultures from mastoid infections may be negative in up to 33-53% of cases, emphasizing the importance of clinical diagnosis 3
Treatment success rates vary, with antibiotics alone having a 10% success rate, antibiotics plus myringotomy having a 68% success rate, and antibiotics plus mastoidectomy having a 22% success rate 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends initial management with consideration of the predominance of Streptococcus pneumoniae as the causative organism, with ceftriaxone as a second-line option 5
Streptococcus pneumoniae remains the most common causative organism despite PCV-13 vaccination, with other important pathogens including Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas aeruginosa 5
Mastoidectomy rates vary widely, reflecting practice variation rather than disease severity, with success rates by treatment modality including antibiotics alone, antibiotics plus myringotomy, and antibiotics plus mastoidectomy 5
Consider surgery if there is no improvement after 48 hours of IV antibiotics, development of complications, or presence of subperiosteal abscess, though needle aspiration may be attempted first 5