CITW 15: The Red Ear

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 5 year old female with a history of recurrent otitis media who presents to the ED with right ear pain. Per the parents, she developed acute onset right ear pain and “redness” one week ago that was associated with fevers (Tm 103.2). She saw her pediatrician who started a course of Augmentin for otitis media, however, after three days of no improvement, she received IM antibiotics (unknown type) with only minimal improvement in symptoms. On the day of ED presentation, her ear redness had worsened and she had developed limited range of motion of the head and neck. Associated symptoms included headache, hearing loss, and sore throat. No congestion, runny nose, conjunctivitis, visual changes, numbness, weakness, discoordination, cough, dyspnea, wheezing, abdominal pain, vomiting, diarrhea, or rash. No sick contacts or recent travel. Shots are up to date.

Vital Signs: T 102.3, HR 156, RR 22, BP 118/72, SpO2 99% on RA

Pertinent physical exam: Patient found sitting on her mother’s lap, not playful or interactive. Right TM is erythematous and bulging. There is edema and erythema noted behind the right auricle with tenderness to palpation. Shotty cervical chain adenopathy appreciated. No ear discharge. Left TM is clear. Oropharynx is clear with moist mucous membranes. No focal or gross neurological deficits. No meningismus. Neck is supple. Heart is tachycardic. Abdomen soft, non-tender. Lungs clear to auscultation. No rashes. No other pertinent exam findings.

CT imaging was obtained:

Mastoiditis 1
Image 1: CT brain, axial cuts in bone window.
Mastoiditis 2
Image 2: CT brain, coronal cuts in bone window.

What’s the diagnosis?


Mastoiditis

In the above CT imaging, note the diffuse opacification of the right sided mastoid air cells, consistent with a diagnosis of mastoiditis.

Here are some quick facts:

  • Bacterial infection of the mastoid cells occurs most often as an extension of an otitis media. Here you can see how easily an infection can extend out from the middle ear:
    Mastoid anatomy
    Figure 1: Middle ear anatomy.1
  • The incidence is highest in children 12-36 months of age, and is associated with recurrent otitis media infections, immunocompromised state, or the presence of a cholesteaoma.
  • The three most common organisms isolated are Strep Pneumoniae, nontypeable H. influenzae, and M. catarrhalis.
  • Clinical features include fever and ear pain, with more specific features of erythema, edema, and tenderness of the mastoid area posterior to the auricle:
    Mastoiditis 3
    Figure 2: Clinical features of mastoiditis, including erythema and edema posterior to the auricle.2
  • As the disease progresses you can see proptosis of the affected ear and/or palsies of cranial nerves VI or VII:
    Proptosis
    Figure 3: Right ear proptosis.3
  • Complications include intracranial abscess, meningitis, and otitic hydrocephalus secondary to thrombosis of the transverse and/or sigmoid venous sinuses.
  • The diagnosis is clinical, but is confirmed by CT of the mastoid.
  • Treatment includes broad spectrum antibiotics, which should be narrowed once the organism and susceptibilities are identified.
  • ENT consult is recommended for myringotomy (+/- tympanostomy tubes) and/or mastoidectomy for cases associated with extramastoid spread of disease.

Of note, this patient had extramastoid spread of her infection, identified as a subperiosteal abscess over the mastoid bone with thrombus in the distal right transverse and sigmoid sinus.

Mastoid 3Image 3: Low density material noted in the right sigmoid dural sinus with similar enhancement/density to the adjacent mastoiditis.

No flow
Figure 4: MRV confirming lack of flow in the right sigmoid, transverse, and internal jugular vein.

Case Conclusion:

The patient was started on broad spectrum antibiotics and admitted to the pediatric ICU. She underwent mastoidectomy and tympanostomy tube placement in the operating room by ENT. She was discharged with a three week course of oral antibiotics, and a three month course of lovenox.

References:

1: Drake, et. al. Gray’s Anatomy for Students. <www.studentconsult.com>. 2016.

2: Mastoiditis. <www.netterimages.com>. 2016.

3: Mastoiditis. <me.hawkelibrary.com>. 2016.

4: Lau, Steve. Mastoid Mass with Associated Transverse and Sigmoid Sinus Thrombosis. <http://radiopaedia.org/cases/mastoid-mass-with-associated-transverse-and-sigmoid-sinus-thrombosis>. 2016.

5: Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 945-946; 763-764.

Shout out to Dr. Chris Merritt for this case!

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

Faculty Reviewer: Dr. Alyson McGregor

See you again soon!

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