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Acute mastoiditis in children: Treatment and prevention

Acute mastoiditis in children: Treatment and prevention
Literature review current through: Jan 2024.
This topic last updated: May 05, 2023.

INTRODUCTION — Acute mastoiditis is the most common suppurative complication of acute otitis media (AOM) [1]. In many cases, it is the first evidence of AOM [2-4].

The treatment and prevention of acute mastoiditis in children are discussed below. The clinical features and diagnosis of acute mastoiditis are discussed separately. (See "Acute mastoiditis in children: Clinical features and diagnosis".)

AOM is also discussed separately. (See "Acute otitis media in children: Epidemiology, microbiology, and complications" and "Acute otitis media in children: Clinical manifestations and diagnosis" and "Acute otitis media in children: Treatment".)

DEFINITIONS

Mastoiditis is a suppurative infection of the mastoid air cells.

Acute mastoiditis is a suppurative infection of the mastoid air cells with symptoms of less than one month's duration. Acute mastoiditis is subdivided according to the pathologic stage (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Pathogenesis') [1]:

Acute mastoiditis with periostitis (also called incipient mastoiditis) is defined by the presence of purulent material in the mastoid cavities without destruction of the bony septa. The finding of fluid in the mastoid air cells on imaging is nonspecific and is commonly seen in children with acute otitis media (AOM) or otitis media with effusion. Thus, this finding alone is not diagnostic of mastoiditis. The diagnosis is based on clinical findings, including postauricular tenderness, erythema, and swelling with protrusion of the auricle (picture 1). (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Diagnosis'.)

Coalescent mastoiditis (also called "acute mastoid osteitis") is defined by destruction of the thin bony septae between air cells (image 1). This imaging finding is diagnostic of mastoiditis; however, most children do not require imaging to make the diagnosis (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Indications for imaging'). Coalescent mastoiditis may be followed by the formation of abscess cavities and the dissection of pus into adjacent areas, the most common of which is subperiosteal abscess.

Subacute mastoiditis (also called "masked mastoiditis") refers to low-grade but persistent infection in the middle ear and mastoid with destruction of the bony septae between air cells [5]. It occurs in patients with persistent otitis media with effusion or recurrent episodes of AOM without sufficient antimicrobial therapy.

Chronic mastoiditis is a suppurative infection of the mastoid air cells of longstanding duration (months to years) [6].

Complicated mastoiditis refers to mastoiditis with one or more extracranial or intracranial complications (figure 1).

MICROBIOLOGY — The bacterial species most often implicated in acute mastoiditis are Streptococcus pneumoniae and Streptococcus pyogenes. Less commonly, Fusobacterium necrophorum, Haemophilus influenzae (nontypeable), Staphylococcus aureus (including methicillin-resistant S. aureus), and Pseudomonas aeruginosa are recovered. P. aeruginosa is a consideration for children with a history of recurrent acute otitis media (AOM) or recent antibiotic use. Cultures performed on swabs of drainage from the external auditory canal are likely to be contaminated and may not reflect the true pathogenic organisms. The microbiology of acute mastoiditis in children is discussed in greater detail separately. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Microbiology'.)

MANAGEMENT APPROACH — The treatment of acute mastoiditis depends upon the stage as well as presence or absence and type of complications (table 1) [1,7]. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Pathogenesis' and "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications'.)

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 and the approach to management varies from center to center [1]. The recommendations below are based upon information from observational studies [3,8-14].

Referral — Consultation with an otolaryngologist should occur early in the disease course [1,6]. Aspiration and drainage of the middle ear are necessary for diagnostic and therapeutic purposes (see 'Drainage' below). Consultation with a neurosurgeon may be warranted for children with clinical or radiologic evidence of an intracranial complication. In addition, consultation with a pediatric infectious disease expert can help guide antimicrobial therapy.

Uncomplicated disease — For most children with uncomplicated acute or subacute (masked) mastoiditis, we suggest initial conservative management, consisting of intravenous (IV) antimicrobial therapy and middle ear drainage with myringotomy (with or without placement of a tympanostomy tube [TT]). (See 'Antimicrobial therapy' below and 'Drainage' below.)

Most children with uncomplicated acute or subacute mastoiditis can be managed without mastoidectomy. However, patients should be monitored daily for clinical response and simple mastoidectomy should be performed if there is no clinical improvement in systemic and local findings within 48 hours. Imaging is not necessary for patients with uncomplicated disease unless they do not respond to treatment. (See 'Treatment response' below.)

The practice of initial conservative management for children with uncomplicated mastoiditis is supported by several retrospective studies [3,8-16]. The reported success rates of conservative therapy in these studies range from 60 to 97 percent. Most of the studies included a mix of patients with uncomplicated and complicated disease. Differences in the relative proportions of each likely explain the wide range in the reported success rates.

Complicated disease — For children with suppurative extracranial or intracranial complications of acute mastoiditis other than facial nerve paralysis, we suggest initial aggressive surgical management with mastoidectomy in addition to IV antimicrobial therapy and myringotomy (with TT insertion) rather than conservative management alone [1,12,17,18].

Suppurative complications include subperiosteal abscess, Bezold abscess (a neck abscess located beneath the sternocleidomastoid and digastric muscles), osteomyelitis involving other parts of the skull, suppurative labyrinthitis, meningitis, subdural abscess, epidural abscess, brain abscess, cerebellar abscess, or septic dural sinus thrombosis (figure 1). (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Complications'.)

Acute mastoiditis complicated by isolated facial nerve paralysis can be managed conservatively initially [9]. (See 'Uncomplicated disease' above.)

Practice varies regarding management of children with subperiosteal abscess. We typically perform simple mastoidectomy (in conjunction with antibiotic therapy and myringotomy) if there are clinical findings indicating the presence of a subperiosteal abscess (eg, postauricular fluctuance or mass (picture 2)) or if computed tomography (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 [9,12,14]. Some experts favor postauricular aspiration as the initial procedure for children with a small subperiosteal abscess [19].

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) [1,7]. (See 'Drainage' below.)

ANTIMICROBIAL THERAPY — The treatment of mastoiditis requires parenteral antimicrobial therapy. However, antimicrobial therapy alone usually is not sufficient, particularly in the later stages of the disease process, when it may be difficult to achieve adequate antibiotic levels in the bony tissue [8].

Empiric therapy – Choice of empiric antimicrobial therapy for children with acute mastoiditis depends upon whether there is a history of recurrent acute otitis media (AOM) or recent antibiotic therapy (table 2):

Children without recurrent AOM or recent antibiotics – For children without a history of recurrent AOM or recent antibiotic administration (ie, within six months), we suggest empiric antimicrobial therapy with ampicillin-sulbactam (50 mg/kg intravenously [IV] every six hours; maximum daily dose 12 g) (table 2). The most frequent bacterial pathogens are S. pneumoniae and S. pyogenes. F. necrophorum, H. influenzae (nontypeable), and S. aureus (including methicillin-resistant S. aureus) are recovered less often.

Children with recurrent AOM or recent antibiotics – For children with a history of recurrent AOM (most recent episode within six months) or recent antibiotic use, we suggest piperacillin-tazobactam at 75 mg/kg IV every six hours (maximum daily dose 16 g). Suggested empiric regimens are summarized in the table (table 2).

Additional or alternative antimicrobial agents may be warranted in some circumstances, including:

If there are clinical signs of sepsis at the time of presentation, in whom vancomycin should be added to the empiric regimen (see "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Empiric regimens')

If there are specific complications (eg, intracranial abscess abscess) (see "Intracranial epidural abscess", section on 'Empiric antimicrobial therapy')

If the child does not improve with the initial empiric regimen

Pathogen-specific therapy – When results of culture and susceptibility testing are available, antimicrobial therapy should be adjusted accordingly. Common pathogens include:

S. pneumoniae (see "Invasive pneumococcal (Streptococcus pneumoniae) infections and bacteremia in adults", section on 'Treatment')

S. pyogenes (see "Invasive group A streptococcal infections in children", section on 'Treatment')

S. aureus (including methicillin-resistant S. aureus) (see "Staphylococcus aureus in children: Overview of treatment of invasive infections")

Duration of therapy – We usually treat with IV antibiotics for 7 to 10 days and then transition to oral antibiotics to complete a four-week course (the usual duration for treatment of osteomyelitis). Transition to oral antibiotics can occur when the child has improved clinically and culture and susceptibility results are available [20-22]. In observational studies, the duration of treatment varies depending on the severity of the infection, with extended courses for children with intracranial complications [14,23]. Indirect evidence supporting a four-week duration of antibiotic therapy is provided from studies in children with hematogenous osteomyelitis, which are discussed separately. (See "Hematogenous osteomyelitis in children: Management", section on 'Total duration'.)

DRAINAGE — Treatment of acute mastoiditis generally requires the drainage of pus from the middle ear and/or mastoid cavity. Antimicrobial therapy alone is usually not sufficient, particularly in the later stages of the disease process, when it may be difficult to achieve adequate antibiotic levels in the bony tissue [8]. In addition, early drainage may interrupt the pathologic process and prevent complications [8]. Although there are reports of successful treatment without tympanocentesis or myringotomy [3], we do not advocate such an approach, since aspiration of middle ear fluid is crucial in guiding definitive antimicrobial therapy.

Practice varies from center to center regarding the use of different drainage procedures (tympanocentesis, myringotomy, myringotomy with placement of tympanostomy tube [TT], mastoidectomy) based on the pathologic stage (acute mastoiditis with periostitis versus coalescent mastoiditis) and presence or absence and type of complications [1,7,24]. (See 'Management approach' above.)

Tympanocentesis – At a minimum, tympanocentesis should be performed in all children with mastoiditis to obtain middle ear fluid for culture and susceptibility testing [1]. Obtaining samples for culture is extremely important to allow therapy to be tailored to the individual patient. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Microbiologic studies'.)

Myringotomy – Myringotomy (surgical perforation of the tympanic membrane) permits drainage of the middle ear; it may be performed with or without placement of a TT. Myringotomy permits drainage of the mastoid if the aditus ad antrum is not blocked (figure 2) [1]. A wide-field, large myringotomy should be performed in children with acute mastoid osteitis to ensure adequate drainage [1].

TT placement – TTs permit drainage over a longer duration than myringotomy alone [1]. At most institutions, it is standard to place a TT when myringotomy is performed to ensure sustained drainage. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children" and "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes'.)

Mastoidectomy – Mastoidectomy is the surgical removal of the mastoid cortical bone and underlying air cells. In simple mastoidectomy (also called cortical, complete, or canal-wall-up mastoidectomy), the posterior portion of the external auditory canal is preserved. In radical mastoidectomy (also called canal-wall-down mastoidectomy), the posterior portion of the external auditory canal is sacrificed.

Simple mastoidectomy is performed to clean out the mastoid infection, open the aditus ad antrum, and provide external drainage [1]. Radical mastoidectomy is performed only when there is no clinical response to simple mastoidectomy, as evidenced by continued otorrhea or pain [1].

Indications for mastoidectomy may include [1,6,24]:

Clinical findings consistent with subperiosteal abscess, such as postauricular fluctuance or mass (picture 2), regardless of CT findings.

Other suppurative complications of acute mastoiditis (eg, Bezold abscess, osteomyelitis involving other parts of the skull, suppurative labyrinthitis, meningitis, subdural abscess, epidural abscess, brain abscess, cerebellar abscess, or septic dural sinus thrombosis) (figure 1) – Suppurative intratemporal or intracranial complications may require additional surgical intervention(s) to address the specific complication (eg, drainage of intratemporal or intracranial collections). (See "Intracranial epidural abscess", section on 'Management' and "Septic dural sinus thrombosis", section on 'Surgery'.)

CT evidence of a sizable fluid collection, mastoid air cell coalescence, or cortical bone erosion – In general, imaging is warranted only in patients with clinical findings suggestive of an extra- or intracranial complication and such patients typically have another indication for mastoidectomy. However, if CT imaging is performed without an indication and demonstrates one of these concerning findings, mastoidectomy is usually warranted even in the absence of other clinical findings.

Acute mastoiditis in a child with chronic suppurative otitis media or cholesteatoma. (See "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention", section on 'Surgery' and "Cholesteatoma in children", section on 'Surgical treatment'.)

Progression of postauricular swelling or fluctuance or persistence of fever, ear pain, or drainage despite appropriate intravenous (IV) antimicrobial therapy and tympanocentesis/myringotomy.

TREATMENT RESPONSE — The response to treatment of acute mastoiditis is monitored through serial examination of the postauricular region, external auditory canal, and tympanic membrane for improvement or resolution of clinical findings [1,7] (see "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Clinical features'):

Fever

Otalgia

Postauricular tenderness, erythema, swelling, fluctuance, or mass

Protrusion of the auricle

Sagging or edema (narrowing) of the external auditory canal

In patients with acute mastoiditis with periostitis, periosteal involvement usually resolves within 24 to 48 hours after tympanocentesis/myringotomy and initiation of adequate antimicrobial therapy [1]. Mastoidectomy is indicated in children who do not demonstrate adequate treatment response after 24 to 48 hours. Imaging of the temporal bone also may be indicated (to evaluate the development of intratemporal complications) [1,6].

Similarly, patients with acute coalescent mastoiditis or complications who have been treated with intravenous (IV) antibiotics, myringotomy, and mastoidectomy usually demonstrate clinical improvement within 24 to 48 hours of initiation of treatment. Radical mastoidectomy may be indicated for patients with persistent symptoms [1]. Imaging (if not previously performed) or repeat imaging of the temporal bone also may be warranted in patients with persistent or worsening symptoms to evaluate the development of intratemporal complications [1,6].

OUTCOME — The outcome of acute mastoiditis depends upon the extent of infection [6,17]. Most children with acute mastoiditis that is appropriately treated early in the course recover without complications or long-term sequelae (eg, hearing loss) [9,17]. Intracranial extension may be associated with permanent neurologic deficits or death. Hearing loss is uncommon but can occur, particularly if treatment is delayed or if there is a history of recurrent acute or chronic otitis media. Hearing loss can be conductive, sensorineural, or mixed. It is most often conductive due to damage to the middle ear, though sensorineural hearing loss can occur from suppurative labyrinthitis causing damage to the cochlea [6].

FOLLOW-UP — Audiology should be performed during the convalescence of children with acute mastoiditis to determine if they have hearing loss and, if so, whether it is conductive or sensorineural [6]. (See "Hearing loss in children: Screening and evaluation", section on 'Formal audiology'.)

Children who develop intracranial complications of acute mastoiditis should be followed for the development of adverse neurologic and/or otologic effects (eg, sensorineural hearing loss). (See "Developmental-behavioral surveillance and screening in primary care" and "Hearing loss in children: Screening and evaluation".)

PREVENTION — Early, adequate treatment of acute otitis media (AOM) reduces the risk of developing mastoiditis but does not eliminate it altogether [4,8,25-27]. In a retrospective cohort study, the rate of mastoiditis was 1.8 versus 3.8 per 10,000 episodes of AOM that were treated and not treated with antibiotics, respectively [25].

Other possible preventive strategies include interventions to prevent recurrent AOM and immunization with the pneumococcal conjugate vaccine. These are discussed separately. (See "Acute otitis media in children: Prevention of recurrence" and "Pneumococcal vaccination in children".)

Prompt treatment of acute mastoiditis and early evaluation of persistent ear drainage, ear pain, or AOM that is not responding to antimicrobial therapy may decrease the risk of developing complications of mastoiditis [6].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute otitis media, otitis media with effusion, and external otitis".)

SUMMARY AND RECOMMENDATIONS

Definition – Acute mastoiditis is a suppurative infection of the mastoid air cells with symptoms of less than one month's duration. It may be uncomplicated or complicated (ie, associated with one or more extra- or intracranial complications (figure 1)). (See 'Definitions' above.)

Microbiology – The bacterial species most often implicated in acute mastoiditis are Streptococcus pneumoniae and Streptococcus pyogenes. Less often, Fusobacterium necrophorum, Haemophilus influenzae (nontypeable), and Staphylococcus aureus are recovered. Pseudomonas aeruginosa is a consideration for children with a history of recurrent acute otitis media (AOM) or recent antibiotic use. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Microbiology'.)

Surgical consultation – Consultation with an otolaryngologist should occur early in the disease course. Consultation with a neurosurgeon may be warranted for children with clinical or radiologic evidence of an intracranial complication. In addition, consultation with a pediatric infectious disease expert can help guide antimicrobial therapy. (See 'Referral' above.)

Management approach – The treatment of acute mastoiditis depends upon the pathologic stage as well as presence or absence and type of complications. Antimicrobial therapy and drainage of the middle ear and mastoid are the cornerstones of therapy (table 1). (See 'Management approach' above.)

Uncomplicated disease – For children with uncomplicated acute or subacute (masked) mastoiditis, we suggest initial conservative management rather than aggressive surgical management (Grade 2C). Conservative management consists of intravenous (IV) antimicrobial therapy and middle ear drainage with myringotomy (with or without placement of a tympanostomy tube [TT]). Patients should be monitored daily for clinical response, and mastoidectomy should be performed if there is no clinical improvement within 48 hours. (See 'Uncomplicated disease' above and 'Treatment response' above.)

Complicated disease – For children with suppurative extracranial or intracranial complications of acute mastoiditis other than facial nerve paralysis (figure 1), we suggest initial aggressive surgical management with mastoidectomy in addition to IV antimicrobial therapy and myringotomy (with TT insertion) rather than conservative therapy alone (Grade 2C). Acute mastoiditis complicated by isolated facial nerve paralysis can be managed conservatively initially. (See 'Complicated disease' above and 'Drainage' above.)

Empiric antibiotic choice – Treatment of mastoiditis requires parenteral antimicrobial therapy. The choice of initial empiric antimicrobial therapy for children with acute mastoiditis depends upon whether there is a history of recurrent AOM or recent antibiotic therapy (table 2) (see 'Antimicrobial therapy' above):

For children without a history of recurrent AOM or recent antibiotic administration, we suggest empiric antimicrobial therapy with ampicillin-sulbactam (Grade 2C)

For children with a history of recurrent AOM or recent antibiotic use, we suggest piperacillin-tazobactam as initial empiric therapy (Grade 2C) because of its activity against P. aeruginosa

Tailoring antibiotics and duration of therapy – When results of culture and susceptibility testing are available, antimicrobial therapy should be adjusted accordingly. The total duration of antimicrobial therapy is four weeks. Transition to oral antibiotics can occur when the child has improved clinically and culture and susceptibility results are available. (See 'Antimicrobial therapy' above.)

Outcome – Most children with acute mastoiditis that is appropriately treated early in the course recover without complications or long-term sequelae. Intracranial extension may be associated with permanent neurologic deficits or death. Permanent hearing loss is an uncommon complication. (See 'Outcome' above.)

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