Acute Mastoiditis Management

Algorithm Steps

1. ▶

   Start

   Suspected Acute Mastoiditis

   Patient (often <2 years) with: post-auricular swelling/erythema, tenderness over mastoid, protruding pinna, fever. Often preceded by acute otitis media.

   1. ●

      Action

      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
      1. ◆

         Decision

         Signs of Intracranial Complications?

         Red flags: altered mental status, severe headache, neck stiffness, focal neurological signs, papilledema, cranial nerve palsies (especially VI, VII).

         1. ⚠

            Warning

            ⚠️ 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.

            1. ●

               Action

               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
               1. ●

                  Action

                  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
                  1. ◆

                     Decision

                     Subperiosteal Abscess Present?

                     CT shows rim-enhancing collection behind ear? Fluctuance on exam?

                     1. ●

                        Action

                        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.

                        1. ◆

                           Decision

                           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.

                           1. ●

                              Action

                              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.

                              1. ✓

                                 Outcome

                                 Post-Mastoidectomy Care

                                 Continue IV antibiotics. Drain removal 48-72h. Mastoid dressings. Antibiotic/steroid ear drops. Audiology assessment. Follow-up for wound care.

                           2. ●

                              Action

                              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.

                              1. ✓

                                 Outcome

                                 Infection Controlled

                                 Complete antibiotic course. Audiology follow-up (conductive hearing loss may persist). ENT follow-up to confirm resolution. Counsel on ear infection prevention.

                           3. ●

                              Action

                              Monitor for Complications

                              Watch for: facial nerve palsy, labyrinthitis (vertigo), hearing loss, Bezold abscess (SCM), Gradenigo syndrome (CN VI palsy + otitis), sigmoid sinus thrombosis.

                  2. ●

                     Action

                     Myringotomy ± Tubes

                     If intact TM: myringotomy for drainage and culture. Place tympanostomy tube if recurrent. Provides microbiological data to guide antibiotic therapy.