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Acute Otitis Media Clinical Pathway – All Settings – Complications of Otitis Media Including Mastoiditis

Acute Otitis Media Clinical Pathway – All Settings

Complications of Otitis Media Including Mastoiditis

  • Mastoiditis
  • Facial nerve palsy—consult ENT
  • Meningitis
  • Other intracranial complications

Acute Mastoiditis

General Principles

  • Acute mastoiditis is a clinical diagnosis characterized by proptosis of the ear, erythema, swelling, fluctuance, and/or tenderness of the mastoid process.
    • Isolated mastoid effusion on CT in the absence of these clinical findings is not diagnostic of acute mastoiditis. This finding is nonspecific and may be seen in other conditions, such as acute otitis media or viral upper respiratory infection. Interpret CT findings in the context of the clinical presentation.
  • CT imaging is recommended for evaluation of intracranial extension or abscess.
  • Consult ENT for possible surgical intervention.
  • Consult infectious disease for acute mastoiditis with intracranial extension (e.g., epidural or subdural abscess), subperiosteal or subcutaneous abscess, bony destruction, or failure to improve after 48–72 hrs of antibiotic therapy.
  • Mastoiditis without intracranial extension and with adequate source control is generally treated for 14 days. Longer treatment duration may be necessary for inadequate source control or intracranial extension.

Common Pathogens

  • Streptococcus pneumoniae (pneumococcus)
  • Streptococcus pyogenes (GAS)
  • Staphylococcus aureus
    • Methicillin-susceptible Staphylococcus aureus > methicillin-resistant S. aureus
  • Nontypeable Haemophilus influenzae
  • M. catarrhalis
Pseudomonas aeruginosa and anaerobes rarely cause acute mastoiditis.

Antibiotic Therapy for Acute Mastoiditis

Indications First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative
Acute Mastoiditis without Intracranial Extension
  • Ampicillin-sulbactam, IV
    • 50 mg/kg/dose of ampicillin component every 6 hours
    • Max: 2000 mg/dose
  • or
  • Amoxicillin-clavulanate, PO
    • < 3 months:
      • 30 mg/kg/day of amoxicillin component in 2 divided doses
    • ≥ 3 months:
      • 90 mg/kg/day of amoxicillin component in 2 divided doses
      • Max: 2000 mg/dose
  • Levofloxacin, IV or PO
    • ≥ 6 months and < 5 years:
      • 10 mg/kg/dose twice daily
      • Max: 375 mg/dose
    • ≥ 5 years:
      • 10 mg/kg/dose daily
      • Max: 750 mg/dose
Acute Mastoiditis with Intracranial Extension
  • Ceftriaxone, IV
    • 50 mg/kg/dose every 12 hours
    • Max: 2000 mg/dose
  • and
  • Vancomycin, IV
    • ≤ 50 kg and < 18 years:
      • 15 mg/kg/dose every 6 hours
      • Max: 750 mg/dose
    • > 50 kg or ≥ 18 years:
      • 15 mg/kg/dose every 8 hours
      • Max: 1000 mg/dose
  

CHOP Formulary for complete drug information.