Amoxicillin in the Treatment of Mastoiditis: Efficacy, Challenges, and Future Directions

ENT Updates

Review

Amoxicillin in the Treatment of Mastoiditis: Efficacy, Challenges, and Future Directions

Khalid, W., Alzahrani, M., Alqahtani, G., Mushayt, R., Sinan, A. A., Alsultani, S., Alenezi, A., Alenezi, K., Alanazi, L., Abdullah, T., Abdullah, K., Daban, M., Samah, N., & Farhan, M. (2026). Amoxicillin in the Treatment of Mastoiditis: Efficacy, Challenges, and Future Directions. ENT Updates, 16(1), 1–18. https://doi.org/10.54963/entu.v16i1.1671

Authors

  • Wajan Khalid

    College of Pharmacy, King Khalid University, Abha 62521, Saudi Arabia
  • Manar Alzahrani

    College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
  • Ghassan Alqahtani

    Department of Pharmacy, AlNahdi Medical Company, Jeddah 21484, Saudi Arabia
  • Razan Mushayt

    Department of Pharmacy, Abha International Private Hospital, Abha 62521, Saudi Arabia
  • Ayat Al Sinan

    College of Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia
  • Sadeem Alsultani

    College of Pharmacy, Northern Borders University, Rafha 76413, Saudi Arabia
  • Aryam Alenezi

    Department of Pharmacy Services, Prince Abdulaziz Bin Musaad Hospital, Arar 91451, Saudi Arabia
  • Khawlah Alenezi

    Department of Pharmacy Services, Prince Abdulaziz Bin Musaad Hospital, Arar 91451, Saudi Arabia
  • Lama Alanazi

    Department of Pharmacy Services, Prince Abdulaziz Bin Musaad Hospital, Arar 91451, Saudi Arabia
  • Tahani Abdullah

    Department of Nursing, Northern Area Armed Forces Hospital, Hafar Al Batin 31991, Saudi Arabia
  • Khadijah Abdullah

    Department of Supply, Northern Area Armed Forces Hospital, Hafar Al Batin 31991, Saudi Arabia
  • Mohammed Daban

    Department of Supply, Northern Area Armed Forces Hospital, Hafar Al Batin 31991, Saudi Arabia
  • Naif Samah

    Department of Supply, Northern Area Armed Forces Hospital, Hafar Al Batin 31991, Saudi Arabia
  • Modhi Farhan

    Department of Supply, Northern Area Armed Forces Hospital, Hafar Al Batin 31991, Saudi Arabia

Received: 30 September 2025; Revised: 15 December 2025; Accepted: 20 January 2026; Published: 28 January 2026

Mastoiditis, a serious complication of acute otitis media, primarily affects the pediatric population and requires prompt diagnosis and treatment to prevent severe complications. This review explores the pathophysiology, clinical presentation, diagnostic techniques, and therapeutic approaches for mastoiditis, focusing on the role of amoxicillin in its management. The anatomical connection between the middle ear and mastoid air cells facilitates the spread of infection, which is further influenced by inflammatory processes, bacterial biofilms, and host immune responses. Diagnosis involves a combination of clinical findings, imaging studies such as computed tomography and magnetic resonance imaging, and microbiological cultures to guide targeted antibiotic therapy. Amoxicillin remains the first-line treatment for non-resistant cases owing to its effectiveness against common pathogens, safety profile, and cost efficiency. However, the increasing prevalence of β-lactamase-producing bacteria necessitates the use of amoxicillin-clavulanate in resistant cases. Antibiotic selection should be based on local resistance patterns and patient-specific factors, such as allergies and comorbidities. Surgical interventions, including mastoidectomy, are required in advanced or refractory cases. Future research should focus on developing novel diagnostic tools, optimizing antibiotic regimens, and implementing antimicrobial stewardship programs to combat drug resistance. Global collaboration is essential for establishing standardized guidelines and improving access to high-quality care in resource-limited settings.

Keywords:

Mastoiditis Otitis Media Amoxicillin Antimicrobial Therapy Diagnostic Techniques Imaging Antibiotic Resistance

References

  1. Favre, N.; Patel, V.A.; Carr, M.M. Complications in Pediatric Acute Mastoiditis: HCUP KID Analysis. Otolaryngol. Head Neck Surg. 2021, 165, 722–730. DOI: https://doi.org/10.1177/0194599821989633
  2. Schwam, Z.G.; Ferrandino, R.; Kaul, V.Z.; et al. The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database. Otology Neurotol. 2020, 41, 1084–1093. DOI: https://doi.org/10.1097/MAO.0000000000002745
  3. Alshehri, S.; Alahmari, K.A. Pediatric Acute Mastoiditis in Saudi Arabia: Demographic Insights, Clinical Profiles, and Prognostic Factors. Children 2024, 11, 402. DOI: https://doi.org/10.3390/children11040402
  4. Lee, K.J.; Ryoo, I.; Choi, D.; et al. Performance of Deep Learning to Detect Mastoiditis Using Multiple Conventional Radiographs of Mastoid. PLoS One 2020, 15, e0241796. DOI: https://doi.org/10.1371/journal.pone.0241796
  5. Heywood, E.G.; Stubington, T.; Chandarana, K.; et al. Complications of Acute Mastoiditis in a Paediatric Population at a UK Tertiary Centre: A Retrospective Review. Clin. Otolaryngol. 2024, 49, 264–269. DOI: https://doi.org/10.1111/coa.14128
  6. Kaufmann, M.R.; Shetty, K.; Camilon, P.R.; et al. Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis. Pediatr. Infect. Dis. J. 2022, 41, 297–301. DOI: https://doi.org/10.1097/INF.0000000000003452
  7. Samuel, O.; Saliba, W.; Stein, N.; et al. Epidemiology of Pediatric Acute Mastoiditis in Israel: A National Registry 10-Year Perspective. Laryngoscope Investig. Otolaryngol. 2022, 7, 2139–2144. DOI: https://doi.org/10.1002/lio2.948
  8. Edwards, S.; Kumar, S.; Lee, S.; et al. Epidemiology and Variability in Management of Acute Mastoiditis in Children. Am. J. Otolaryngol. 2022, 43, 103520. DOI: https://doi.org/10.1016/j.amjoto.2022.103520
  9. Hoberman, A.; Paradise, J.L.; Rockette, H.E.; et al. Reduced-Concentration Clavulanate for Young Children with Acute Otitis Media. Antimicrob. Agents Chemother. 2017, 61, e00238-17. DOI: https://doi.org/10.1128/AAC.00238-17
  10. Busch, L.M.; Kadri, S.S. Antimicrobial Treatment Duration in Sepsis and Serious Infections. J. Infect. Dis. 2020, 222, S142–S155. DOI: https://doi.org/10.1093/infdis/jiaa247
  11. Namivandi-Zangeneh, R.; Wong, E.H.H.; Boyer, C. Synthetic Antimicrobial Polymers in Combination Therapy: Tackling Antibiotic Resistance. ACS Infect. Dis. 2021, 7, 215–253. DOI: https://doi.org/10.1021/acsinfecdis.0c00635
  12. Liu, C.; Hong, Q.; Chang, R.Y.K.; et al. Phage-Antibiotic Therapy as a Promising Strategy to Combat Multidrug-Resistant Infections and to Enhance Antimicrobial Efficiency. Antibiotics 2022, 11, 570. DOI: https://doi.org/10.3390/antibiotics11050570
  13. Sawyer, R.G.; Claridge, J.A.; Nathens, A.B.; et al. Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection. N. Engl. J. Med. 2015, 372, 1996–2005. DOI: https://doi.org/10.1056/NEJMoa1411162
  14. Hoberman, A.; Paradise, J.L.; Rockette, H.E.; et al. Treatment of Acute Otitis Media in Children under 2 Years of Age. N. Engl. J. Med. 2011, 364, 105–115. DOI: https://doi.org/10.1056/NEJMoa0912254
  15. Anthonsen, K.; Høstmark, K.; Hansen, S.; et al. Acute Mastoiditis in Children: A 10-Year Retrospective and Validated Multicenter Study. Pediatr. Infect. Dis. J. 2013, 32, 436–440. DOI: https://doi.org/10.1097/INF.0b013e31828abd13
  16. Tang, B.-H.; Wu, Y.-E.; Kou, C.; et al. Population Pharmacokinetics and Dosing Optimization of Amoxicillin in Neonates and Young Infants. Antimicrob. Agents Chemother. 2019, 63, e02336-18. DOI: https://doi.org/10.1128/AAC.02336-18
  17. Savage, T.J.; Kronman, M.P.; Sreedhara, S.K.; et al. Treatment Failure and Adverse Events After Amoxicillin-Clavulanate vs Amoxicillin for Pediatric Acute Sinusitis. JAMA 2023, 330, 1064–1073. DOI: https://doi.org/10.1001/jama.2023.15503
  18. KuKanich, K.; Lubbers, B.; Salgado, B. Amoxicillin and Amoxicillin-Clavulanate Resistance in Urinary Escherichia coli Antibiograms of Cats and Dogs from the Midwestern United States. J. Vet. Intern. Med. 2020, 34, 227–231. DOI: https://doi.org/10.1111/jvim.15674
  19. Aladeyelu, O.S.; Olaniyi, K.S.; Olojede, S.O.; et al. Temporal Bone Pneumatization: A Scoping Review on the Growth and Size of Mastoid Air Cell System with Age. PLoS One 2022, 17, e0269360. DOI: https://doi.org/10.1371/journal.pone.0269360
  20. Fernández-Reyes, B.A.; Guzman-Lopez, S.; Arrambide-Garza, F.J.; et al. Middle Ear Morphology and Mastoid Pneumatisation: A Computed Tomography Study. Folia Morphol. 2025, 84, 108–116. DOI: https://doi.org/10.5603/fm.100190
  21. Adışen, M.Z.; Aydoğdu, M. Comparison of Mastoid Air Cell Volume in Patients with or without a Pneumatized Articular Tubercle. Imaging Sci. Dent. 2022, 52, 27–32. DOI: https://doi.org/10.5624/isd.20210153
  22. Singh, A.; Thakur, R.; Kumar, R.; et al. Grading of the Position of the Mastoid Tegmen in Human Temporal Bones—A Surgeon’s Perspective. J. Int. Adv. Otol. 2020, 16, 63–66. DOI: https://doi.org/10.5152/iao.2020.7748
  23. Gülay Aslan, G.; Yagiz Aghayarov, O.; Pekçevik, Y.; et al. Comparison of Tympanometric Volume Measurement with Temporal Bone CT Findings in the Assessment of Mastoid Bone Pneumatization in Chronic Otitis Media Patients. Eur. Rev. Med. Pharmacol. Sci. 2023, 27, 6–10. DOI: https://doi.org/10.26355/eurrev_202310_34063
  24. Sioshansi, P.C.; Alyono, J.C.; Blevins, N.H. Mastoid Obliteration Using Autologous Bone Dust Following Canal Wall Down Mastoidectomy. Otology Neurotol. 2021, 42, 68–75. DOI: https://doi.org/10.1097/MAO.0000000000002839
  25. Chen, Y.; Hu, J.; Liu, W.; et al. The Treatment of Cholesteatomas Involving the Antrum and Mastoid Using Transcanal Underwater Endoscopic Ear Surgery. Otology Neurotol. 2020, 41, 1379–1386. DOI: https://doi.org/10.1097/MAO.0000000000002813
  26. Chen, N.; Hou, Q.; Cui, Z.; et al. Effect of Otitis Media with Effusion and Its Clinical Intervention on the Development of Mastoid in Children. Acta Otolaryngol. 2014, 134, 481–484. DOI: https://doi.org/10.3109/00016489.2013.878810
  27. Lampikoski, H.; Aarnisalo, A.A.; Jero, J.; et al. Mastoid Biofilm in Chronic Otitis Media. Otology Neurotol. 2012, 33, 785–788. DOI: https://doi.org/10.1097/MAO.0b013e318259533f
  28. Kim, D.; Kim, S.; Kwon, Y.; et al. Structural Insights for β-Lactam Antibiotics. Biomol. Ther. 2023, 31, 141–147. DOI: https://doi.org/10.4062/biomolther.2023.008
  29. Shin, E.; Nantongo, M.; Dousa, K.M.; et al. 2806. The Mechanism of β-Lactam Antibiotic Action: Structural Analysis of Mycobacterium abscessus l,d-Transpeptidases, d,d-Carboxypeptidase and Penicillin-Binding Proteins Binding by Imipenem, Ceftaroline, and Amoxicillin. Open Forum Infect. Dis. 2023, 10, ofad500.2417. DOI: https://doi.org/10.1093/ofid/ofad500.2417
  30. Elsbroek, L.; Amiteye, D.; Schreiber, S.; et al. Molecular Imaging of Isolated Escherichia coli DH5α Peptidoglycan Sacculi Identifies the Mechanism of Action of Cell Wall-Inhibiting Antibiotics. ACS Chem. Biol. 2023, 18, 848–860. DOI: https://doi.org/10.1021/acschembio.2c00945
  31. Koutouzis, E.I.; Michos, A.; Koutouzi, F.I.; et al. Pneumococcal Mastoiditis in Children Before and After the Introduction of Conjugate Pneumococcal Vaccines. Pediatr. Infect. Dis. J. 2016, 35, 292–296. DOI: https://doi.org/10.1097/INF.0000000000000995
  32. Laakso, J.T.; Rissanen, V.; Ruotsalainen, E.; et al. Severe Acute Otitis Media and Mastoiditis Caused by Group A Beta-Hemolytic Streptococcus. Laryngoscope Investig. Otolaryngol. 2021, 6, 1158–1166. DOI: https://doi.org/10.1002/lio2.659
  33. Kaur, R.; Casey, J.R.; Pichichero, M.E. Relationship with Original Pathogen in Recurrence of Acute Otitis Media after Completion of Amoxicillin/Clavulanate: Bacterial Relapse or New Pathogen. Pediatr. Infect. Dis. J. 2013, 32, 1159–1162. DOI: https://doi.org/10.1097/INF.0b013e31829e3779
  34. Shiran, S.I.; Pratt, L.T.; DeRowe, A.; et al. The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis. AJNR Am. J. Neuroradiol. 2024, 45, 761–768. DOI: https://doi.org/10.3174/ajnr.A8217
  35. Anne, S.; Schwartz, S.; Ishman, S.L.; et al. Medical Versus Surgical Treatment of Pediatric Acute Mastoiditis: A Systematic Review. Laryngoscope 2019, 129, 754–760. DOI: https://doi.org/10.1002/lary.27462
  36. Dharmapalan, D.; Bielicki, J.; Sharland, M. Harmonization of Amoxicillin Dose, Duration, and Formulation for Acute Childhood Respiratory Infections. Antibiotics 2023, 12, 1138. DOI: https://doi.org/10.3390/antibiotics12071138
  37. Telles, J.P.; Morales, R.; Yamada, C.H.; et al. Optimization of Antimicrobial Stewardship Programs Using Therapeutic Drug Monitoring and Pharmacokinetics-Pharmacodynamics Protocols: A Cost-Benefit Review. Ther. Drug Monit. 2023, 45, 200–208. DOI: https://doi.org/10.1097/FTD.0000000000001067
  38. Palmer, M.E.; Andrews, L.J.; Abbey, T.C.; et al. The Importance of Pharmacokinetics and Pharmacodynamics in Antimicrobial Drug Development and Their Influence on the Success of Agents Developed to Combat Resistant Gram Negative Pathogens: A Review. Front. Pharmacol. 2022, 13, 888079. DOI: https://doi.org/10.3389/fphar.2022.888079
  39. Yang, Q.; Zhang, C.; Liu, X.; et al. The Pharmacokinetics and Pharmacodynamics of Cefquinome against Streptococcus agalactiae in a Murine Mastitis Model. PLoS One 2023, 18, e0278306. DOI: https://doi.org/10.1371/journal.pone.0278306
  40. Frost, H.M.; Dominguez, S.; Parker, S.; et al. 1342. Clinical Failure Rates of Amoxicillin for the Treatment of Acute Otitis Media in Young Children. Open Forum Infect. Dis. 2020, 7, S682–S683. DOI: https://doi.org/10.1093/ofid/ofaa439.1524
  41. Csonka, P.; Palmu, S.; Heikkilä, P.; et al. Outpatient Antibiotic Prescribing for 357,390 Children With Otitis Media. Pediatr. Infect. Dis. J. 2022, 41, 947–952. DOI: https://doi.org/10.1097/INF.0000000000003693
  42. Choffor-Nchinda, E.; Atanga, L.C.; Nansseu, J.R.; et al. Effectiveness of Amoxicillin Alone in the Treatment of Uncomplicated Acute Otitis Media: A Systematic Review Protocol. BMJ Open 2018, 8, e021133. DOI: https://doi.org/10.1136/bmjopen-2017-021133
  43. Harmes, K.M.; Blackwood, R.A.; Burrows, H.L.; et al. Otitis Media: Diagnosis and Treatment. Am. Fam. Physician 2013, 88, 435–440.
  44. Dukić, S.; Matijević, S.; Daković, D.; et al. Comparison of Cefixime and Amoxicillin Plus Metronidazole in the Treatment of Chronic Periodontitis. Vojnosanit. Pregl. 2016, 73, 526–530. DOI: https://doi.org/10.2298/vsp150326133d
  45. Jehan, F.; Nisar, I.; Kerai, S.; et al. Randomized Trial of Amoxicillin for Pneumonia in Pakistan. N. Engl. J. Med. 2020, 383, 24–34. DOI: https://doi.org/10.1056/NEJMoa1911998
  46. Kuzucu, F.N.; Genis, C.; Sengül Emeksiz, Z.; et al. Assessment of the Safety of Alternative Antibiotics in Children with Confirmed Beta-Lactam Antibiotic Allergy. Int. Arch. Allergy Immunol. 2025, 186, 465–472. DOI: https://doi.org/10.1159/000542013
  47. Rusu, A.; Munteanu, A.-C.; Arbănași, E.-M.; et al. Overview of Side-Effects of Antibacterial Fluoroquinolones: New Drugs versus Old Drugs, a Step Forward in the Safety Profile? Pharmaceutics 2023, 15, 804. DOI: https://doi.org/10.3390/pharmaceutics15030804
  48. Aspinall, S.L.; Sylvain, N.P.; Zhao, X.; et al. Serious Cardiovascular Adverse Events with Fluoroquinolones versus Other Antibiotics: A Self-Controlled Case Series Analysis. Pharmacol. Res. Perspect. 2020, 8, e00664. DOI: https://doi.org/10.1002/prp2.664
  49. Xiong, Y.L.; Peng, C.; Deng, Y.J.; et al. Amoxicillin-Associated Hemorrhagic Colitis: A Case Report and Literature Review. Medicine 2024, 103, e40800. DOI: https://doi.org/10.1097/MD.0000000000040800
  50. Andjelić, S.; Savić, S.; Kozić, D. Amoxicillin-Clavulanate Prescribed in a Patient with Known Penicillin Allergy. Srpski Arh. Celok. Lek. 2020, 148, 493–496. DOI: https://doi.org/10.2298/SARH191222024A
  51. Gómez Caballero, N.; Almenara, S.; Tévar Terol, A.; et al. Anaphylaxis Probably Induced by Transfer of Amoxicillin via Oral Sex. BMJ Case Rep. 2019, 12, e227398. DOI: https://doi.org/10.1136/bcr-2018-227398
  52. Kim, S.-H.; Saide, K.; Farrell, J.; et al. Characterization of Amoxicillin- and Clavulanic Acid-Specific T Cells in Patients with Amoxicillin-Clavulanate-Induced Liver Injury. Hepatology 2015, 62, 887–899. DOI: https://doi.org/10.1002/hep.27912
  53. Chaabane, N.B.; Safer, L.; Njim, L.; et al. Cholestatic Hepatitis Related to Amoxicillin. Drug Chem. Toxicol. 2011, 34, 357–358. DOI: https://doi.org/10.3109/01480545.2010.545067
  54. Olesen, S.W.; Barnett, M.L.; MacFadden, D.R.; et al. The Distribution of Antibiotic Use and Its Association with Antibiotic Resistance. eLife 2018, 7, e39435. DOI: https://doi.org/10.7554/eLife.39435
  55. Goebel, M.C.; Trautner, B.W.; Grigoryan, L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin. Microbiol. Rev. 2021, 34, e00003-20. DOI: https://doi.org/10.1128/CMR.00003-20
  56. Mudenda, S.; Mukosha, M.; Godman, B.; et al. Knowledge, Attitudes, and Practices of Community Pharmacy Professionals on Poultry Antibiotic Dispensing, Use, and Bacterial Antimicrobial Resistance in Zambia: Implications on Antibiotic Stewardship and WHO AWaRe Classification of Antibiotics. Antibiotics 2022, 11, 1210. DOI: https://doi.org/10.3390/antibiotics11091210
  57. Charani, E.; Holmes, A. Antibiotic Stewardship—Twenty Years in the Making. Antibiotics 2019, 8, 7. DOI: https://doi.org/10.3390/antibiotics8010007
  58. Abrams, E.M.; Ben-Shoshan, M. Should Testing Be Initiated Prior to Amoxicillin Challenge in Children?. Clin. Exp. Allergy 2019, 49, 1060–1066. DOI: https://doi.org/10.1111/cea.13443
  59. Searns, J.B.; Stein, A.; MacBrayne, C.; et al. 1332. Single Dose Oral Amoxicillin Challenge Is a Safe and Effective Strategy to Delabel Penicillin Allergies among Low Risk Hospitalized Children. Open Forum Infect. Dis. 2020, 7, S677–S678. DOI: https://doi.org/10.1093/ofid/ofaa439.1514
  60. Gervais, C.; Panetta, L.; Roy, H.; et al. 83 Success of Amoxicillin Oral Challenges in Children at Low Risk of Allergy Requiring Antibiotic in the Emergency Department. Paediatr. Child Health 2023, 28, e39. DOI: https://doi.org/10.1093/pch/pxad055.083
  61. Morelo Torres, C.; Eymann, A.; Petriz, N.; et al. Diagnostic Confirmation of Amoxicillin Allergy in Children Treated at the Division of Pediatric Allergy. Arch. Argent. Pediatr. 2020, 118, 47–51. DOI: https://doi.org/10.5546/aap.2020.eng.47
  62. Carter, E.J.; Zavez, K.; Rogers, S.C.; et al. Documented Penicillin Allergies on Antibiotic Selection at Pediatric Emergency Department Visits. Pediatr. Emerg. Care 2024, 40, 283–288. DOI: https://doi.org/10.1097/PEC.0000000000003023
  63. Malkawi, W.A.; AlRafayah, E.; AlHazabreh, M.; et al. Formulation Challenges and Strategies to Develop Pediatric Dosage Forms. Children 2022, 9, 488. DOI: https://doi.org/10.3390/children9040488
  64. Karaaslan, A.; Cetin, C.; Kole, M.T.; et al. Acute Mastoiditis in Children: A Tertiary Care Center Experience in 2015–2021. Niger. J. Clin. Pract. 2023, 26, 347–351. DOI: https://doi.org/10.4103/njcp.njcp_392_22
  65. Lopes-de-Campos, D.; Pinto, R.M.; Lima, S.A.C.; et al. Delivering Amoxicillin at the Infection Site—A Rational Design through Lipid Nanoparticles. Int. J. Nanomedicine 2019, 14, 2781–2795. DOI: https://doi.org/10.2147/IJN.S193992
  66. Güncüm, E.; Işıklan, N.; Anlaş, C.; et al. Development and Characterization of Polymeric-Based Nanoparticles for Sustained Release of Amoxicillin—An Antimicrobial Drug. Artif. Cells Nanomed. Biotechnol. 2018, 46, 964–973. DOI: https://doi.org/10.1080/21691401.2018.1476371
  67. Torres-Figueroa, A.V.; Pérez-Martínez, C.J.; del Castillo-Castro, T.; et al. Composite Hydrogel of Poly(Acrylamide) and Starch as Potential System for Controlled Release of Amoxicillin and Inhibition of Bacterial Growth. J. Chem. 2020, 2020, 5860487. DOI: https://doi.org/10.1155/2020/5860487
  68. Fujiwara, R.J.T.; Alonso, J.E.; Ishiyama, A. Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States. Otology Neurotol. 2021, 42, 733–739. DOI: https://doi.org/10.1097/MAO.0000000000003050