Suspected Acute Mastoiditis
Patient (often <2 years) with: post-auricular swelling/erythema, tenderness over mastoid, protruding pinna, fever. Often preceded by acute otitis media.
All Pathways
OtolaryngologyEmergency
Acute Mastoiditis Management
Acute Mastoiditis Management: Suspected Acute Mastoiditis → Clinical Examination → Signs of Intracranial Complications? → ⚠️ Intracranial Complication →...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Clinical Examination
Look for: Post-auricular swelling, erythema, tenderness. Pinna pushed forward and outward. Sagging of posterior-superior canal wall on otoscopy. Signs of AOM (bulging TM, otorrhea).
- Median age: 12 months
- Fever usually present
- May have preceding AOM or concurrent URI
03Decision Signs of Intracranial Complications?
Red flags: altered mental status, severe headache, neck stiffness, focal neurological signs, papilledema, cranial nerve palsies (especially VI, VII).
04Warning ⚠️ Intracranial Complication
STAT: CT head/temporal bones with contrast. MRI/MRV if sigmoid sinus thrombosis suspected. Neurosurgery consult. Complications: meningitis, brain abscess, epidural abscess, sigmoid sinus thrombophlebitis.
05Action CT Temporal Bones with Contrast
Confirms diagnosis, assesses for: subperiosteal abscess, coalescent mastoiditis (bony destruction), intracranial extension. Identifies patients needing surgery.
- CT preferred over MRI for bony detail
- Look for rim-enhancing fluid collections
- Assess for sinus thrombosis
06Action IV Antibiotics
Start immediately. First-line: Ceftriaxone 50-100mg/kg/day (max 2g) or Cefotaxime. Cover S. pneumoniae, H. influenzae, S. pyogenes, S. aureus. Add Vancomycin if MRSA concern or toxic.
- Blood cultures before antibiotics
- Continue IV until afebrile 48 hours
- Then oral antibiotics x 14 days total
07Decision Subperiosteal Abscess Present?
CT shows rim-enhancing collection behind ear? Fluctuance on exam?
08Action Abscess Drainage
Options: Needle aspiration (less invasive, can be bedside in older children) OR Incision & drainage (more definitive). Send for aerobic AND anaerobic cultures. Some advocate for mastoidectomy if large abscess.
09Decision Response to IV Antibiotics at 48h?
Is patient improving? Fever resolved? Swelling decreasing? If no improvement after 48 hours of appropriate IV antibiotics, surgical intervention indicated.
10Action Cortical Mastoidectomy
Indications: No improvement on IV Abx x 48h, large subperiosteal abscess, coalescent mastoiditis on CT, intracranial complications. Drains mastoid air cells, removes infected bone.
11Outcome Post-Mastoidectomy Care
Continue IV antibiotics. Drain removal 48-72h. Mastoid dressings. Antibiotic/steroid ear drops. Audiology assessment. Follow-up for wound care.
12Action Continue Medical Management
If improving: continue IV antibiotics until afebrile 48h. Then transition to oral antibiotics (Augmentin) for total 14 days. Remove drains 48-72h post-op if applicable.
13Outcome Infection Controlled
Complete antibiotic course. Audiology follow-up (conductive hearing loss may persist). ENT follow-up to confirm resolution. Counsel on ear infection prevention.
14Action Monitor for Complications
Watch for: facial nerve palsy, labyrinthitis (vertigo), hearing loss, Bezold abscess (SCM), Gradenigo syndrome (CN VI palsy + otitis), sigmoid sinus thrombosis.
- Path rejoins step 13Shared downstream outcome
- Path rejoins step 09Shared downstream outcome
15Action Myringotomy ± Tubes
If intact TM: myringotomy for drainage and culture. Place tympanostomy tube if recurrent. Provides microbiological data to guide antibiotic therapy.
- Path rejoins step 05Shared downstream outcome
Guideline Source
ENT-UK Mastoiditis Flowchart + StatPearls + Hopkins Protocol
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Most common in children <2 years
- Intracranial complications require neurosurgery
- Antibiotic resistance patterns vary regionally
- Does not address chronic mastoiditis
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Acute Mastoiditis Management?
The Acute Mastoiditis Management is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on ENT-UK Mastoiditis Flowchart + StatPearls + Hopkins Protocol.
What guideline is the Acute Mastoiditis Management based on?
This algorithm is based on ENT-UK Mastoiditis Flowchart + StatPearls + Hopkins Protocol (DOI: NBK526099).
What are the limitations of the Acute Mastoiditis Management?
Known limitations include: Most common in children <2 years; Intracranial complications require neurosurgery; Antibiotic resistance patterns vary regionally; Does not address chronic mastoiditis. Individual patient factors may require deviation from these recommendations.
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