Suspected acute mastoiditis
Redness, swelling, tenderness or fluctuance behind the ear, a protruding ear, and signs of acute otitis media. Mostly young children; adults can be affected. Discuss every patient with ENT.
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OtolaryngologyEmergency
Acute Mastoiditis Management
Acute Mastoiditis Management: Suspected acute mastoiditis → Assess: vital signs, GCS, neurology, ear → Before antibiotics: allergy, neonate, chronic ear...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Assess: vital signs, GCS, neurology, ear
Look for sepsis, reduced GCS, meningism, headache, focal neurological signs, cranial nerve palsy (VI, VII) and papilloedema. Otoscopy: bulging drum or discharge.
- Blood culture, FBC and CRP; swab any ear discharge. Do not delay antibiotics for tests.
- Ask about: beta-lactam allergy, cochlear implant, grommets, chronic ear disease or cholesteatoma, MRSA.
- Age under 4 weeks: the antibiotic regimens here do not apply. Discuss with paediatrics or ID.
03Warning Before antibiotics: allergy, neonate, chronic ear disease
Cochlear implant: urgent ENT discussion. Renal impairment: adjust vancomycin and cefepime doses. Seek advice, but do not delay the first antibiotic dose in an unwell patient.
- High-risk beta-lactam allergy (immediate reaction, anaphylaxis, SJS/TEN, DRESS): discuss with ID before any beta-lactam. Intracranial signs or sepsis: give the non-beta-lactam regimen now.
- Neonate: ceftriaxone is contraindicated if under 41 weeks postmenstrual age, jaundiced, or on IV calcium-containing fluids.
- Chronic ear disease or Pseudomonas from the ear: ceftriaxone is not enough. Use cefepime (see antibiotic steps).
04Decision Intracranial signs or sepsis?
Yes if any: GCS below 15, meningism, headache, focal neurological signs, seizures, cranial nerve VI palsy, papilloedema, or sepsis.
- If Yes
05Warning Intracranial signs or sepsis: antibiotics now, imaging after
Give IV antibiotics within 60 minutes. Do not wait for CT, MRI or lumbar puncture. Sepsis or shock: resuscitate now and also follow the sepsis pathway.
- Take blood culture first only if it does not delay antibiotics.
- Defer lumbar puncture if focal signs, seizures, markedly reduced GCS, shock or coagulopathy.
- Suspected bacterial meningitis: also follow the meningitis pathway (dexamethasone timing).
06Action Intracranial signs or sepsis: IV ceftriaxone (meningitic dose) plus vancomycin
Child 4 weeks or older: ceftriaxone 50 mg/kg (max 2 g) IV 12-hourly. Adult: ceftriaxone 2 g IV 12-hourly. Give ceftriaxone first, then vancomycin. High-risk beta-lactam allergy: use the allergy regimen below; do not delay.
- Vancomycin, child: 15 mg/kg (max initial dose 750 mg) IV 6-hourly by slow infusion. TDM required; adjust in renal impairment.
- Vancomycin, adult: dose per eTG Antibiotic or local guideline. TDM required.
- High-risk beta-lactam allergy, child: moxifloxacin 10 mg/kg (max 400 mg) IV once daily in place of ceftriaxone, plus vancomycin. Adult: regimen per eTG Antibiotic or ID. Call ID now; do not delay the first dose.
- Chronic ear disease or Pseudomonas: cefepime 50 mg/kg (max 2 g) IV 8-hourly in place of ceftriaxone. Discuss with ID.
- Brain abscess, venous sinus thrombosis or slow response: agree the regimen and duration with ID.
07Action Intracranial signs or sepsis: urgent CT with contrast and/or MRI
After antibiotics start. Contrast CT of temporal bones and brain. MRI with contrast (and MR venography) if abscess or venous sinus thrombosis is suspected or CT is unclear. Urgent ENT, ID and neurosurgery.
- Brain or epidural abscess: neurosurgery; a combined ENT and neurosurgery approach may be needed.
- Venous sinus thrombosis: consider anticoagulation; consult haematology.
- Mastoid or subperiosteal abscess: ENT drainage (see surgery step).
- No complication on imaging: continue IV antibiotics and reassess at 24-48 h.
08Decision Improving after 24-48 h of IV antibiotics?
Improving: less fever, pain and swelling, and no new signs. New headache, drowsiness, cranial nerve palsy, neck swelling or fluctuance at any time: urgent imaging and ENT review.
- If Yes
09Action Improving: complete 12-15 days of antibiotics
IV for at least 5 days, then oral to complete 12-15 days in total (ChAMP WA). Choose the oral drug by culture results.
- No pathogen, child: amoxicillin-clavulanate 25 mg/kg (max 875 mg amoxicillin) orally 12-hourly.
- No pathogen, adult: amoxicillin-clavulanate 875 mg/125 mg orally 12-hourly.
- Low-risk penicillin allergy, child: cefuroxime 15 mg/kg (max 500 mg) orally 12-hourly. High-risk: azithromycin 10 mg/kg (max 500 mg) orally daily.
- MRSA, or intracranial complication: agree the oral drug and duration with ID.
10Outcome Improving: discharge with close follow-up
ENT follow-up to confirm resolution. Hearing test after recovery. Return at once for headache, drowsiness, vomiting, neck stiffness, new swelling or facial weakness.
If No11Action Not improving at 24-48 h: imaging and ENT surgery
Contrast CT and/or MRI if not done. ENT options: needle aspiration, incision and drainage, cortical mastoidectomy, grommet. Send pus for aerobic and anaerobic culture. Involve microbiology or ID.
- Intracranial complication on imaging: follow the intracranial steps above (meningitic doses, neurosurgery).
12Outcome After drainage or mastoidectomy
Continue IV antibiotics and adjust to culture results. Total 12-15 days; longer for intracranial complications, as agreed with ID. Hearing test and ENT follow-up.
If No13Action No intracranial signs: admit, IV ceftriaxone
Start now. Child 4 weeks or older: ceftriaxone 50 mg/kg (max 2 g) IV once daily. Adult: ceftriaxone 2 g IV once daily. Urgent ENT review.
- Known or suspected MRSA: add vancomycin. Child: 15 mg/kg (max initial dose 750 mg) IV 6-hourly. Adult: dose per eTG Antibiotic or local guideline. TDM required.
- Chronic ear disease or Pseudomonas: cefepime 50 mg/kg (max 2 g) IV 8-hourly in place of ceftriaxone.
- Low-risk penicillin allergy (delayed rash only): give ceftriaxone. High-risk allergy: discuss with ID.
- Routine CT is not needed if there are no complication signs.
14Decision Abscess, fever or other local complication?
Yes if any: fluctuant swelling behind the ear, fever, neck swelling below the ear (Bezold abscess), facial nerve palsy, or vertigo.
- If Yes
15Action Abscess or local complication: urgent ENT, consider imaging
Consider contrast CT and/or MRI. Abscess: ENT drainage by needle aspiration, incision and drainage, or cortical mastoidectomy, with or without a grommet. Send pus for aerobic and anaerobic culture.
- Facial nerve palsy: urgent ENT review.
- Continue IV antibiotics; adjust to culture results.
- Path rejoins step 08Shared downstream outcome
If No- Path rejoins step 08Shared downstream outcome
Guideline Source
ENT UK Clinical Guideline: Management of acute mastoiditis in children (2021), with PCH ChAMP Ear, Nose, Throat and Dental Paediatric Empiric Guidelines (reviewed Nov 2024) for antibiotics
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotic regimens are for children aged 4 weeks or older and adults; for neonates, discuss with paediatrics or ID.
- Not for chronic mastoiditis, cholesteatoma or necrotising otitis externa (skull base osteomyelitis).
- Adult doses follow product information and the paediatric maximum doses; no adult mastoiditis guideline was used.
- Antibiotic choice varies with local resistance; follow eTG or the local hospital guideline.
Contraindicated Populations
Neonates under 4 weeks (antibiotic regimens do not apply)
Applicable Regions
AUNZUKEUUS
AU: Antibiotic doses follow the Perth Children's Hospital ChAMP ENT guideline (Nov 2024). In the Kimberley, Pilbara, Goldfields and other areas with high MRSA rates, have a lower threshold to add vancomycin. Check eTG Antibiotic or the local guideline.
UK: Pathway structure follows the ENT UK 2021 acute mastoiditis flowchart; use local antibiotic policy.
Version 2Next review: 2027-09-30
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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 Clinical Guideline: Management of acute mastoiditis in children (2021), with PCH ChAMP Ear, Nose, Throat and Dental Paediatric Empiric Guidelines (reviewed Nov 2024) for antibiotics.
What guideline is the Acute Mastoiditis Management based on?
This algorithm is based on ENT UK Clinical Guideline: Management of acute mastoiditis in children (2021), with PCH ChAMP Ear, Nose, Throat and Dental Paediatric Empiric Guidelines (reviewed Nov 2024) for antibiotics.
What are the limitations of the Acute Mastoiditis Management?
Known limitations include: Antibiotic regimens are for children aged 4 weeks or older and adults; for neonates, discuss with paediatrics or ID.; Not for chronic mastoiditis, cholesteatoma or necrotising otitis externa (skull base osteomyelitis).; Adult doses follow product information and the paediatric maximum doses; no adult mastoiditis guideline was used.; Antibiotic choice varies with local resistance; follow eTG or the local hospital guideline.. Individual patient factors may require deviation from these recommendations.
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