Treatment of Sternomastoiditis
The initial treatment for sternomastoiditis should include a combination of intravenous antibiotics and consideration for surgical drainage if there is evidence of abscess formation or lack of improvement after 48 hours of antibiotic therapy. 1
Diagnostic Approach
Before initiating treatment, proper diagnosis is essential:
- High-resolution temporal bone CT scan with contrast is the first-line imaging modality to assess bone destruction and identify complications
- MRI should be considered when intracranial complications are suspected or better soft tissue characterization is needed
Antibiotic Therapy
First-line antibiotic options:
- Cloxacillin/flucloxacillin IV
- Ceftriaxone IV
- Vancomycin plus piperacillin-tazobactam
- Vancomycin plus a carbapenem
- Vancomycin plus ceftriaxone and metronidazole
For penicillin-allergic patients:
- Clindamycin (10-20 mg/kg/day in 3 divided doses for children; 300-450 mg 3 times daily for adults)
Duration of therapy:
- Total antibiotic therapy typically lasts 2-3 weeks
- Initial IV therapy followed by oral therapy continuing for at least 7-10 days after IV completion
Surgical Management
Surgical intervention is indicated in the following scenarios:
- Lack of response to 48 hours of IV antibiotics
- Presence of subperiosteal abscess
- Evidence of bone erosion/coalescence
- Development of intracranial complications
Mastoidectomy is a common surgical intervention, performed in up to 77% of cases with complicated sternomastoiditis 1.
Treatment Algorithm
Initial presentation:
- Obtain high-resolution CT temporal bone with contrast
- Start IV antibiotics (see options above)
- Consider myringotomy for drainage and culture if middle ear involvement is present
After 48 hours:
- If improving: Continue IV antibiotics with plan to transition to oral therapy
- If not improving or worsening: Consider surgical intervention (mastoidectomy)
Follow-up:
- Close monitoring is essential
- Reassess within 48-72 hours of starting antibiotics
- Complete full course of antibiotics (2-3 weeks total)
Complications to Monitor
- Intracranial extension
- Venous sinus thrombosis
- Facial nerve paralysis
- Septicemia
Special Considerations
- Prior antibiotic treatment for acute otitis media does not reliably prevent progression to mastoiditis
- Young age, immunocompromised status, delayed treatment, and infection with virulent organisms are risk factors for complications
- Recurrence rates of approximately 4-8% have been reported, with S. pneumoniae infections having a higher recurrence risk
It's important to note that early and aggressive treatment with appropriate antibiotics and timely surgical intervention when indicated provides the best outcomes in terms of morbidity and mortality reduction.