Acute Mastoiditis in Adults and Children

Full title of guideline The management of acute mastoiditis in

children and adults under ENT care

Author Matija Daniel, Consultant ENT Surgeon

Kishan Ubayasiri, ENT registrar
Division and specialty ENT

Scope (Target audience, state if Trust) ENT clinicians, pharmacists

Review date 31st March 2021

Explicit definition of patient group to which it All children and adults suffering with
applies acute mastoiditis under ENT care
Changes from previous version First version

Summary of evidence base this guideline has Expert committee reports or opinions
been created from and / or clinical experiences of
respected authorities
Consultation Process -Discussion and consultation at ENT
departmental meetings
-Paediatric Guidelines Group
-Jaimie Coleman (Consultant in
Emergency Medicine)
-Andrew Wignell (Paediatric pharmacist)
-Annette Clarkson (Pharmacy)
-Shiu Soo (microbiologist)
-NUH Antibiotic Guidelines Committee

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date.

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 Acute Mastoiditis in Adults and Children Guideline

Acute mastoiditis is a suppurative condition which remains a serious

complication of acute otitis media (AOM). It affects 1.4 people per 10,000 per
year in the UK (Ref :NICE. Otitis Media -acute 2009. Available at:
http://cks.nice.org.uk/otitis-media-acute.)

Presentation includes:
 otalgia
 post-auricular inflammation
 auricular protrusion
 signs and symptoms of acute otitis media
 (Masked mastoiditis also occurs, where partially treated infection continues
to cause headache, earache and malaise, but without obvious acute otitis
media)

NB: It is estimated that 5000 children with acute otitis media would need to be
treated with antibiotics to prevent one episode of mastoiditis.

Acute mastoiditis should be treated effectively as delay may lead to severe

intratemporal and potentially lethal intracranial complication. The most
common intracranial complication is meningitis. Be alert to development of
intracranial complication. Any child presenting with possible intracranial
complications including reduced GCS / focal neurology should have paediatric
registrar / consultant review alongside urgent CT imaging and consideration of
other causes.

Otitic hydrocephalus is a rare complication. It presents with symptoms of

raised intracranial pressure such as headache, papilloedema and abducens
palsy.

Samples should be sent to microbiology, when available.

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 Management of Acute Mastoiditis in Adults and Children

Assessment Investigations Treatment Follow-up

CLINICAL PRESENTATION
Signs of acute otitis media
Local inflammation over the
mastoid process:
FBC, U&E CRP and blood cultures ANTIBIOTICS FOLLOW-UP
Ear swab if there is discharge -Otology or Paed ENT OPD in 6-
Intraoperative swabs and tissue if See antibiotic regime tables below 8 weeks
taken to theatre

Pain

Erythema

Auricular protrusion

Loss of post-auricular sulcus RESPONSE TO ANTIBIOTICS

Sagging of posterior / superior
ear canal
IMAGING
Arrange CT head and temporal
bones
Is there a collection amenable
to drainage?
No mastoid abscess or signs of
• Intracranial
intracranial complications
complications on CT –
discuss with
neurosurgery
Signs of intracranial
• Venous sinus thrombosis
complications with or
on CT – discuss with
without mastoid abscess
haematology regarding
(decreased GCS/focal
post-op anticoagulation
neurology) +/- overt mastoid
abscess
Continue IV antibiotics and
consider oral conversion when
significantly improved.
Review microbiology results
and prescribe accordingly.
------------------------------------------
If no improvement after 48
hours:
• CT head and temporal
SURGERY bones if not already
- Inform ENT SpR/Consultant done
- Keep NBM • Discuss with
- Consent patient microbiology
- List for incision and drainage • Consider re-imaging
+/-myringotomy +/- grommet with MR head if
+/- cortical mastoidectomy already had CT

Mastoid abscess but no signs

of intracranial complications
(no decreased GCS/focal
neurology)

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Antibiotic regimes for Adult patients
Note empirical treatment is based on the likely causative organisms.
IV Oral
No Penicillin Co-amoxiclav IV Co-amoxiclav PO 625mg TDS.
allergy 1.2g TDS

Mild Penicillin Cefuroxime IV 1.5g Cefalexin PO 500mg TDS and Metronidazole PO 400mg TDS.
Allergy TDS plus
(e.g. mild rash
Metronidazole IV
alone no
anaphylaxis, or 500mg TDS
immediate onset
urticaria)
Severe Penicillin Levofloxacin IV Levofloxacin PO 500mg BD plus Clindamycin PO 450mg QDS
Allergy e.g. 500mg BD
anaphylaxis,
Plus
angioedema,
urticarial rash in Clindamycin IV
first 72 hours) 600mg QDS
OR
cephalosporin
allergy.

Prolonged antibiotic courses of 2-4 weeks may be required . Treatment should be reviewed with culture and
sensitivity results.

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 Antibiotic regimes for paediatric patients
IV Oral
No Penicillin Under 3 months: Co- Under 1 year: Co-amoxiclav 125/31 suspension 0.5mL/kg three times daily
allergy amoxiclav 30mg/kg 12- 1 year - 5 years: Co-amoxiclav 250/62 suspension 5mL three times daily
hourly
Over 6 years: Co-amoxiclav 250/62 suspension 10mL three times daily
Over 3 months: Over 12 years: Co-amoxiclav 625mg tablet three times daily,
Co-amoxiclav 30mg/kg
(max 1.2g) 8-hourly or 10mL of 250/62 suspension three times daily.
Mild Penicillin Cefuroxime 50mg/kg 1 month–1 year: Cefaclor 125mg three times daily +/-. Metronidazole 7.5mg/kg three times
Allergy (max 1.5g) 8-hourly. daily.
(e.g. mild rash +/- 1 year–12 years: Cefaclor 250mg three times daily +/-. Metronidazole 7.5mg/kg three times
alone no Metronidazole daily.
anaphylaxis, or 7.5mg/kg (max 500mg)
immediate onset 8-hourly. Over 12 years: Cefaclor 500mg three times daily. +/- Metronidazole 7.5mg/kg (max
urticaria) 400mg) three times daily.

Severe Penicillin Clindamycin 10mg/kg Clindamycin 6mg/kg (max 450mg) 6-hourly, plus
Allergy e.g. (max 600mg) 6-hourly Levofloxacin 10mg/kg (max 500mg) 12-hourly**. (There is not a licensed levofloxacin
anaphylaxis, plus suspension available in the UK. A 25mg/mL suspension which is licensed in the USA is
angioedema, Levofloxacin 10mg/kg stocked at NUH for the treatment of mastoiditis. This should be used where patients are
urticarial rash in (max 500mg) 12- unable to swallow tablets. If a 250mg or 500mg dose is appropriate, but the patient is
first 72 hours) hourly**. unable to swallow tablets, the tablets may be crushed as an alternative).
OR
cephalosporin
allergy.

** Levofloxacin use in patients under 18 years is off-label. The dosing recommended here is from the Lexicomp: Paediatric and Neonatal Dosage
Handbook. Accessed via www.uptodate.com on 07/02/2018.