Overview of our approach to the management of acute and subacute mastoiditis in children

	Features	Treatment
Uncomplicated acute mastoiditis	Typically a clinical diagnosis based on fever; otalgia; postauricular erythema, swelling, and tenderness; abnormal tympanic membrane; and protrusion of the auricle	Conservative management initially*
Uncomplicated subacute (masked) mastoiditis	Fever, cough, ear pain, and tympanic membrane findings compatible with AOM; should be considered in children with AOM that is not responding to antibiotics	Conservative management initially*
Acute or subacute mastoiditis with isolated facial nerve paralysis	Unilateral facial paralysis on the same side as the ear findings	Conservative management initially*
Acute mastoiditis with subperiosteal abscess without other complications	Postauricular fluctuance or mass	Aggressive surgical management^¶^Δ
Acute or subacute mastoiditis with CT evidence of coalescent mastoiditis	Loss of definition of the bony septae that define the mastoid air cells	Aggressive surgical management^¶
Acute mastoiditis with suppurative complications, including ≥1 of the following: Bezold abscess Osteomyelitis involving other parts of the skull Suppurative labyrinthitis Meningitis Subdural abscess Epidural abscess Brain abscess Cerebellar abscess Septic dural sinus thrombosis	Signs that raise concern for a suppurative complication include high fevers, irritability, and focal neurologic findings; Bezold abscess is suggested by swelling and tenderness below the mastoid process and under the sternocleidomastoid muscle; most of these diagnoses are confirmed with imaging studies; meningitis is diagnosed with CSF analysis (including culture)	Aggressive surgical management^¶^◊

This table is intended for use in conjunction with additional UpToDate content on mastoiditis in children. Antimicrobial therapy and drainage of the middle ear and mastoid are the cornerstones of therapy for acute mastoiditis. However, treatment of acute mastoiditis in children has not been studied in randomized trials. The approach outlined here represents the management approach at the UpToDate author's institution and is supported by observational studies. The approach to management varies from center to center. Refer to UpToDate's topic on treatment of mastoiditis in children for additional details.

AOM: acute otitis media; CSF: cerebrospinal fluid; CT: computed tomography; IV: intravenous; TT: tympanostomy tube.
* Conservative management includes IV antibiotic therapy plus myringotomy (with or without TT placement). Patients should be monitored daily for clinical response, and mastoidectomy should be performed if there is no clinical improvement within 48 hours.
¶ Aggressive surgical management consists of surgical drainage (usually with simple mastoidectomy) in addition to IV antibiotic therapy and myringotomy (with TT placement).
Δ Practice varies regarding management of children with subperiosteal abscess. We favor aggressive surgical management if there are clinical findings indicating the presence of a subperiosteal abscess (eg, postauricular fluctuance or mass) or if CT (if performed) shows a sizable collection. In the absence of clinical findings, patients with only a small subperiosteal collection on CT can be managed conservatively initially. Other experts favor postauricular aspiration as the initial procedure for children with a small subperiosteal abscess.
◊ Children with suppurative intratemporal or intracranial complications may require additional surgical intervention(s) to address the specific complication (eg, drainage of intratemporal or intracranial collections).

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Overview of our approach to the management of acute and subacute mastoiditis in children