10 y/o with ear pain worsening over the last 5 days (view on ReelDx)
Patient will present as → a 10-year-old boy with otalgia, worsening over the last 5-days and associated with nasal congestion. The patient is afebrile with a temperature of 98 ° F. Examination reveals edema of the external auditory canal producing an anterior and inferior displacement of the auricle with percussion tenderness posteriorly.
Acute mastoiditis is a suppurative infection of the mastoid air cells, usually a complication from preceding acute otitis media
- Clinical features include fever, otalgia, pain and erythema posterior to the ear, and forward displacement of the external ear
- Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, S. pyogenes
History and physical exam. Most cases of mastoiditis can be clinically diagnosed
- CT scan of the temporal bone with contrast is the imaging of choice for complicated mastoiditis or toxic-appearing patients
IV antibiotics + drainage are the mainstay of treatment
- First-line (no recent antibiotics): Ampicillin–sulbactam IV (covers S. pneumoniae, S. pyogenes)
- If recent antibiotics or recurrent AOM: Piperacillin–tazobactam IV (adds Pseudomonas coverage)
- Add vancomycin if severe illness, sepsis, or concern for MRSA
- IV therapy for 7–10 days, then oral antibiotics to complete ~4 weeks total
Procedures
- Myringotomy ± tympanostomy tube for middle ear drainage
- Simple mastoidectomy (drains abscess, removes infected mastoid cells) if no improvement within 48 hrs or if abscess forms
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Question 1 |
A 32 year-old female presents complaining of spiking fevers. She was seen four weeks ago with a complaint of left ear pain and was treated for otitis media. She continues to have symptoms, but now has pain behind the ear. On examination you note left post auricular tenderness and erythema. Which of the following is the treatment of choice in this patient?
IV antibiotics | |
Mastoidectomy Hint: Mastoidectomy is reserved for patients with mastoiditis who fail medical therapy. | |
IM steroids Hint: IM steroids are not indicated in the treatment of mastoiditis. | |
Ventilating tube placement Hint: Ventilating tube placement is indicated in patients with auditory tube dysfunction and chronic serous otitis media. |
Question 1 Explanation:
IV antibiotics are the treatment of choice in a patient with mastoiditis.
Question 2 |
A 5-year-old boy presents with a two-week history of persistent otitis media, despite antibiotic therapy. He now develops swelling and redness behind his right ear along with fever and irritability. Which of the following best describes the pathophysiological progression to the condition suspected in this child?
Viral infection leading to inflammation of the mastoid air cells Hint: While viral infections can precede otitis media, mastoiditis itself is primarily bacterial in nature. | |
Bacterial infection spreading from the middle ear to the mastoid air cells | |
Allergic reaction causing inflammation of the mastoid bone Hint: This does not typically lead to mastoiditis. | |
Fungal infection affecting the external auditory canal extending to the mastoid process Hint: Fungal infections rarely cause mastoiditis. | |
Neoplastic change in the mastoid bone secondary to chronic infection Hint: Chronic infection can lead to complications, but neoplastic change is not a typical progression of mastoiditis. |
Question 2 Explanation:
Mastoiditis typically occurs as a complication of acute otitis media. It involves the spread of bacterial infection from the middle ear to the mastoid air cells, leading to inflammation, infection, and destruction of the bony air cell system. This progression is consistent with the child's history of persistent otitis media followed by symptoms indicative of mastoid involvement.
Question 3 |
A 7-year-old girl is brought to the clinic with a one-week history of right ear pain and a three-day history of swelling behind her right ear. She was treated for otitis media two weeks ago. On examination, there is tenderness, redness, and swelling over the mastoid process. Which of the following is the most appropriate diagnostic test to confirm the suspected diagnosis?
Pure tone audiometry Hint: This test assesses hearing but is not useful for diagnosing mastoiditis. | |
Tympanometry Hint: Useful in diagnosing middle ear effusion but not specific for mastoiditis. | |
CT scan of the temporal bone | |
MRI of the brain Hint: While useful for intracranial complications, it is not the first-line imaging for mastoiditis. | |
Complete blood count (CBC) Hint: May show elevated white blood cells but is non-specific and does not confirm mastoiditis. |
Question 3 Explanation:
In a patient with clinical signs suggestive of mastoiditis, such as history of otitis media followed by pain, swelling, and tenderness over the mastoid process, a CT scan of the temporal bone (with contrast) is the most appropriate diagnostic test. It helps in assessing the extent of the infection, the presence of coalescent mastoiditis, and any intracranial complications.
Question 4 |
A 6-year-old boy diagnosed with acute mastoiditis is not responding to initial intravenous antibiotic therapy. He has no signs of intracranial complications. Which of the following is the most appropriate next step in the management of this patient?
Continue the same antibiotic therapy and observe Hint: This is not appropriate if the patient is not responding to the current antibiotic regimen. | |
Switch to a different class of antibiotics Hint: While this might be considered, it is usually not sufficient in cases of non-response to initial therapy. | |
Myringotomy with or without tympanostomy tube placement Hint: This may be used in the management of otitis media but is not sufficient for mastoiditis not responding to antibiotics. | |
Mastoidectomy | |
Initiate antifungal therapy Hint: Mastoiditis is typically bacterial, not fungal, in etiology. |
Question 4 Explanation:
In cases of acute mastoiditis where the patient does not respond to initial intravenous antibiotic therapy, surgical intervention such as mastoidectomy is often necessary. This procedure involves removing the infected mastoid air cells and is crucial in preventing further complications, especially when there is no response to antibiotics and no intracranial complications are present.
Question 5 |
A 6-year-old boy presents with fever, pain, and tenderness behind the left ear. The parents report that he had an episode of otitis media two weeks ago, which was treated with oral antibiotics. On physical examination, there is erythema, swelling, and tenderness behind the left auricle, along with auricular proptosis. A CT scan of the head reveals opacification of the mastoid air cells on the left side. Which of the following is the most appropriate management for this patient?
Oral antibiotics and observation Hint: Oral antibiotics alone are not sufficient in the treatment of mastoiditis, especially in the presence of systemic symptoms and radiographic evidence of mastoid involvement. This approach would risk further complications, including the spread of the infection. | |
High-dose intravenous antibiotics and myringotomy | |
Tympanostomy tube placement Hint: While tympanostomy tube placement may be considered in recurrent otitis media, it is not the initial treatment for acute mastoiditis. The priority in this case is to control the infection aggressively with intravenous antibiotics and possibly surgical drainage. | |
Surgical mastoidectomy Hint: Surgical mastoidectomy may be required if the infection does not respond to intravenous antibiotics and myringotomy or if there is evidence of complications such as abscess formation. However, it is not the first-line treatment and is reserved for cases where initial management fails. | |
Oral corticosteroids Hint: Oral corticosteroids are not indicated in the management of mastoiditis and could potentially worsen the infection by suppressing the immune response. The primary treatment involves controlling the infection with antibiotics and surgical intervention if necessary. |
Question 5 Explanation:
High-dose intravenous antibiotics and myringotomy is the most appropriate initial management for acute mastoiditis, especially in the presence of symptoms such as fever, pain, tenderness behind the ear, and auricular proptosis. Mastoiditis is a potential complication of otitis media, and the opacification of the mastoid air cells on CT scan indicates infection and inflammation in the mastoid process. Myringotomy allows for drainage of the middle ear, which can reduce pressure and help resolve the infection.
There are 5 questions to complete.
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References: Merck Manual · UpToDate