An 18-month male presents to the ED with left posterior ear swelling for four days. He was seen in the ED two weeks prior for rhinorrhea and diarrhea, at which time he was diagnosed with a viral illness. The patient’s mother reports bloody drainage from the ear for one day, but denies fever, vomiting, rhinorrhea or cough.
It may not be as common as it used to be, but you still can’t afford to miss it.
Case One: 18-month-old boy with left posterior ear swelling for four days. He was seen in the ED two weeks prior for rhinorrhea and diarrhea . . .
An 18-month male presents to the ED with left posterior ear swelling for four days. He was seen in the ED two weeks prior for rhinorrhea and diarrhea, at which time he was diagnosed with a viral illness. The patient’s mother reports bloody drainage from the ear for one day, but denies fever, vomiting, rhinorrhea or cough. The patient has had normal fluid intake and normal urine output. On exam the patient is well appearing but fussy. He is afebrile and mildly tachycardic. His physical exam is normal except for erythema, swelling and mild fluctuance over his left mastoid bone, blood in his external auditory canal, and anterior displacement of his auricle. His right tympanic membrane and external ear exam are unremarkable. The patient underwent a contrasted CT scan, which demonstrated left mastoiditis with focal dehiscence of the lateral temporal bone resulting in an extracranial abscess. There was no evidence of epidural abscess.
Patient number one underwent a contrasted CT scan, which demonstrated left mastoiditis with focal dehiscence of the lateral temporal bone resulting in an extracranial abscess. There was no evidence of epidural abscess.
A 23-month-old female presents to the emergency department with five days of fever, cheek swelling, and not allowing family to touch her face or ears. She was seen three days prior with complaints of fever and left ear pain. Her left TM was obscured by cerumen, but because her right TM was normal, she looked well, was afebrile and had symptoms for less than 48 hours, she was not prescribed antibiotics. During her second visit she has normal vitals, but has noted bilateral mastoid fluctuance and erythema, bilateral anterior ear protuberance, and purulent discharge in her external auditory canals. The patient underwent a contrasted CT scan, which showed bilateral otitis media, bilateral mastoiditis, and a right subperiosteal abscess and epidural abscess.
Case Two: A 23-month-old female presents to the emergency department with five days of fever, cheek swelling, and not allowing family to touch her face or ears. She was seen three days prior with complaints of fever and left ear pain . . .
The mastoid process is one of four anatomical divisions of the temporal bone, and is directly connected to the middle ear via a narrow channel called the aditus ad antrum. In the setting of an upper respiratory tract infection, mucosal secretions and edema accumulate in the middle ear, ultimately backing up into the mastoid air spaces. This process is termed acute otitis media (AOM). In severe cases of AOM, these secretions are unable to drain from the mastoid process, leading to bacterial proliferation, most commonly S. pneumoniae, Group A streptococcus, S. aureus, H. influenzae, and P. aeruginosa.
Once established in the mastoid air cells, the infection—now termed acute mastoiditis—spreads via the mastoid emissary veins into the periosteum, leading to periostitis. If left unchecked, this infection may spread locally within the temporal bone (facial palsy, acute petrositis, labyrinthitis) or outside the temporal bone, either extracranially (postauricular abscess, Bezold’s abscess, zygomatic arch abscess) intracranially (meningitis, epidural abscess, subdural abscess, brain abscess, thrombophlebitis), or both.
The most common systemic signs and symptoms associated with acute mastoiditis include lethargy, malaise or irritability, fever, and poor feeding. According to a recent meta-analysis, the three most common local findings associated with mastoiditis are post-auricular changes (e.g., erythema, tenderness, edema, fluctuance), abnormal TM findings (e.g., erythema, dullness, bulging), and external auditory canal edema or sagging. An ill clinical appearance, lethargy, or neurological symptoms should prompt immediate consultation and/or contrasted CT imaging of the temporal bone. Rarely, a “clinically silent” mastoiditis (“masked” mastoiditis) can progress to focal neurologic or systemic symptoms without obvious exam findings around the ear; this can be the result of an incomplete course of antibiotics for AOM. In these cases, MRI or MR venogram can make the diagnosis.
In the pre-antibiotic era, nearly one in five acute OMs resulted in mastoiditis. Though mastoiditis occurs much less frequently today, it remains a significant cause of morbidity and mortality in the pediatric population. As such, the emergency physician should maintain a high index of clinical suspicion for the disease in children in whom the clinical signs and symptoms discussed above manifest. Once diagnosed on contrasted CT scan, early treatment with vancomycin plus ceftriaxone or ampicillin/sulbactam is recommended. Even in the absence of neurological symptoms and intracranial involvement on the CT scan, otolaryngology should be consulted. If there is intracranial spread or evidence of neurological abnormalities on exam, neurosurgery should be consulted in addition to otolaryngology. The location and extent of the infection will dictate whether surgical intervention is necessary or more conservative measures (e.g., 36-48 hours of IV antibiotic therapy) may be selected.
The patient from case one was initially treated with IV Unasyn, underwent surgical treatment with bilateral myringotomy, placement of tubes and incision and drainage of the postauricular abscess by ENT. He had an uncomplicated post op course and was discharged on ciprofloxacin/dexamethasone otic drops and a 10 day course of Augmentin.
Following initiation of vancomycin and ceftriaxone and neurosurgical evaluation for her epidural abscess, the patient from case two was admitted directly to the OR where otolaryngology performed an I&D of the patient’s subperiosteal abscess followed by placement of bilateral tympanostomy tubes. The patient was treated with vancomycin and ceftriaxone until cultures grew out Group A streptococcus, at which time the vancomycin was stopped. On hospital day four, an MRI was obtained and an LP performed, demonstrating improvement of the epidural abscess and no meningeal involvement. The patient was discharged on hospital day seven, with a plan for daily ceftriaxone infusions for one month and weekly follow up appointments. She recovered without sequelae.
Mariah Bellinger, MD and Andrew P Coleman, MD, MHS are 3rd year EM Residents at the Denver Health Emergency Medicine Residency Program.
Dr. Peter Pryor is an Attending Physician at Denver Health and Assistant Professor of EM at the University of Colorado School of Medicine.
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