Pediatric Mastoiditis Treatment & Management

The treatment of mastoiditis depends upon the stage of the infection and presence and type of complications if present. Antimicrobial therapy and surgical drainage of the middle ear and mastoid cells are the mainstay of therapy.

Medical care for mastoiditis includes intravenous (IV) antimicrobial therapy. The choice of antimicrobial should be based on findings from clinical specimens obtained from the middle ear by tympanocentesis or aspiration. Myringotomy and tympanocentesis are primarily used to obtain specimens and relieve discomfort from acute otitis media (AOM). The openings usually heal within a few days.

After obtaining cultures by means of tympanocentesis or at the time of tympanostomy tube placement with or without mastoidectomy, continue with the initial antibiotic until cultures are reported. If the patient becomes afebrile and if swelling decreases at 48-72 hours, oral medication may be selected on the basis of the culture reports.

Surgical therapy may include mastoidectomy, placement of tympanostomy tubes, and tympanoplasty, as indicated. Treatment of acute mastoiditis varies, depending on the presence or absence of osteitis and periosteitis. Patients with chronic otitis media should be referred to an otolaryngologist. Guidelines for medical management of AOM have been established. ^[38]

Treatment of mastoiditis mandates administration of parenteral antimicrobial therapy. However, this therapy may not necessarily be sufficient, especially in advanced stages the infection. Antimicrobial therapy may not prevent the emergence of complications, as was evident in a series of 223 patients, in whom 8.5% developed complications during antimicrobial treatment. ^[39]

Acute mastoiditis

The antimicrobials used to treat acute mastoiditis include vancomycin plus either ceftriaxone, cefepime (for Pseudomonas), or the combination of a penicillin with a beta-lactamase inhibitor (eg, ampicillin-sulbactam, piperacillin-tazobactam) or a carbapenem.

Aztreonam combined with vancomycin is administered to those with potential severe hypersensitivity (ie, anaphylaxis) to beta-lactam antibiotics.

Parenteral therapy should be given for at least for 7-10 days. Oral therapy can substitute for parenteral treatment (if improvement occurred) for a total of 4 weeks of treatment. Oral agents include clindamycin plus a third-generation cephalosporin or amoxicillin plus clavulanic acid.

Chronic mastoiditis

Treatment of chronic mastoiditis is similar to that of chronic suppurative otitis media (CSOM), which is treated with topical antimicrobial therapy. Thorough aural toilet and systemic antimicrobials are given if this approach fails. The empiric choice of systemic antimicrobials is directed at the eradication of both aerobic and anaerobic bacteria.

Over one half of all gram-negative anaerobic bacteria (eg, pigmented Prevotella, Porphyromonas, Bacteroides, and Fusobacterium) are resistant to penicillins because they produce beta-lactamase. Clindamycin, cefoxitin, metronidazole, chloramphenicol, amoxicillin-clavulanate, or piperacillin-tazobactam provides coverage for anaerobic bacteria.

Coverage for some aerobic bacteria is achieved by using several of these agents. Antimicrobials effective against S aureus and the aerobic gram-negative bacilli, including P aeruginosa, may also be needed. Whenever methicillin-resistant S aureus (MRSA) is present, vancomycin or linezolid should be administered.

An aminoglycoside, a third-generation cephalosporin (eg, ceftazidime, cefepime) or a quinolone (in adults) should be considered for coverage of aerobic gram-negative bacilli, including Pseudomonas. The carbapenems (eg, meropenem) provide single-agent therapy for most of the potential pathogens.

Oral therapy can substitute for parenteral therapy if improvement occurs; treatment should last a total of 6 weeks.

With tympanostomy tube placement, a tube maintains the opening in the tympanic membrane and provides access to the middle ear and mastoid for the administration of antibiotic drops, steroid drops, or both and for drainage without concern about the patency of the eustachian tube. Place the tubes at the time of mastoidectomy, if performed.

Several different types of mastoidectomy procedures are available. Simple (or closed) mastoidectomy is performed through the ear or through an incision behind the ear. The surgeon opens the mastoid bone and removes the infected air cells. The tympanic membrane is incised to drain the middle ear. Topical antibiotics are then placed in the ear.

Radical mastoidectomy removes the most bone and is usually performed for extensive spread of infection. The tympanic membrane and middle ear structures may be completely removed. Usually, the stapes is spared, if possible, to preserve hearing.

In modified radical mastoidectomy, some middle-ear bones are left in place, and the tympanic membrane is reconstructed with tympanoplasty.

Iatrogenic injury during therapy is preventable with facial nerve monitoring, which is now available for use during mastoid surgery. Experienced otologists are unlikely to injure the ossicular chain during mastoid surgery. However, patients and their families should be warned about possible cosmetic deformity after mastoid surgery.

Children who have undergone mastoidectomy are released home after discharge from the surgically implanted drain has abated. The drain is typically removed 48-72 hours after surgery. Antibiotic or steroid drops are continued until the otorrhea ceases and the tympanostomy tube is noted to be open, with healing or healed mucosa behind it.

Acute mastoiditis without osteitis or periosteitis

Consider mastoidectomy for the management of AOM if the patient had pain and fever persisting longer than 48 hours or increasing swelling or tenderness. Otherwise, acute mastoiditis without osteitis or periosteitis is typically associated with AOM and is the only condition of the mastoid that is treated solely with medical therapy.

Management includes the administration of parenteral antimicrobial therapy and myringotomy with or without the placement of a tympanostomy tube. The main goal of therapy is to prevent spread of the infection to the central nervous system (CNS) and to localize the infection. Successful therapy markedly shrinks the abscess, and the periosteal thickening and tenderness decreases within 48 hours.

If complications occur, obtain culture samples through the middle ear, commence new antimicrobial therapy, and image the mastoid. Culture results should guide antimicrobial therapy whenever possible.

Acute mastoiditis with osteitis

Acute mastoiditis with osteitis is a surgically managed disease, though coverage with appropriate antibiotics is mandatory. Mastoidectomy with insertion of a tympanostomy tube is necessary to remove the areas of coalescence in the temporal bone.

Antibiotics should be selected to provide good intracranial penetration and multidrug-resistant S pneumoniae (MDRSP) coverage. With the high incidence of invasive, resistant strains in mastoiditis, initial therapy of IV vancomycin and ceftriaxone or the combination of a penicillin plus a beta-lactamase inhibitor (eg, ampicillin-sulbactam) is most appropriate until the culture and sensitivity results are available.

After surgery, antibiotic drops, steroid drops, or both are used to keep the tube patent and reduce middle-ear swelling.

Patients in whom empyema spreads beyond the mastoid require drainage of the abscess and mastoidectomy. Intracranial spread necessitates a combined neurosurgical and otolaryngologic approach.

Acute mastoiditis with periosteitis

Postauricular swelling and erythema, without subperiosteal abscess or mastoid osteitis, can be treated conservatively by using parenteral antibiotics, high-dose steroids, and insertion of a tympanostomy tube. Vancomycin and ceftriaxone are recommended until culture results become available. If substantial resolution of pain, fever, and erythema does not occur 36-48 hours after the start of therapy, mastoidectomy is warranted.

Early recognition and appropriate treatment of AOM decreases the risk of mastoiditis but does not completely prevent it. The rate of mastoiditis was 1.8 versus 3.8 per 10,000 episodes of AOM in cases treated and not treated with antibiotics, respectively. ^[40]

The conjugated vaccine against invasive S pneumoniae should affect the incidence of pediatric mastoiditis. A study that examined immunization discomfort in children aged 4-6 years concluded that multifaceted distraction intervention significantly reduced pain and discomfort in childhood immunizations. ^[41]

Physicians should be aware of the signs and symptoms of mastoiditis and have a high index of suspicion.

Early consultation with an otolaryngologist is appropriate and necessary if the pediatrician is not comfortable performing tympanocentesis. After the culture results are available, the presence of resistant or unusual microbes may require consultation with an appropriate infectious disease specialist.

Consultation with an otolaryngologist is warranted for those with cervical fluctuance or postauricular fluctuance, mass or swelling, high-spiking fever, imaging studies showing mastoid air cell coalescence, rim-enhancing fluid collection, cortical bone erosion, or intracranial extension. ^[42]

Consultation with a neurologist is also warranted in those who exhibit neurologic signs (eg, meningeal signs, focal deficits, facial weakness, altered level of consciousness, and seizures).

Consultation with a neurosurgeon is appropriate if evidence of intracranial extension with abscess formation is present.

Transfer of the patient is invariably related to the availability of the relevant subspecialists. Available radiographs should be copied and sent with the patient, along with available laboratory data. The patient should take nothing by mouth until the receiving subspecialists can evaluate the condition.

After the discontinuance of IV antibiotics, oral antibiotics should be continued to complete the treatment plan. PO antibiotics that offer the same coverage as the selected IV antibiotic for a given patient should be selected.

After discharge, patients should be followed up by an otolaryngologist. Audiography should be performed. Recurrences were seen in 5% of all patients with acute mastoiditis. ^[43]