A 20-month-old girl is brought to the office due to fever and fussiness for the past 5 days. She has been less playful than usual and is not eating well today. The patient has had several episodes of acute otitis media in the last year, all of which resolved with oral antibiotics. Temperature is 38.6 C (101.5 F), blood pressure is 100/60 mm Hg, and pulse is 120/min. Examination of the right ear reveals a protruded auricle with tenderness and swelling behind the ear. Otoscopy reveals narrowing of the external ear canal; the tympanic membrane cannot be seen. Left ear examination is normal. Which of the following is the most likely diagnosis?

Question

A 20-month-old girl is brought to the office due to fever and fussiness for the past 5 days.  She has been less playful than usual and is not eating well today.  The patient has had several episodes of acute otitis media in the last year, all of which resolved with oral antibiotics.  Temperature is 38.6 C (101.5 F), blood pressure is 100/60 mm Hg, and pulse is 120/min.  Examination of the right ear reveals a protruded auricle with tenderness and swelling behind the ear.  Otoscopy reveals narrowing of the external ear canal; the tympanic membrane cannot be seen.  Left ear examination is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d5f3_e32f_bc81_c918e7609853_MD0003_00 This febrile child with a bulging tympanic membrane, mastoid (eg, behind the ear) tenderness, and displacement of the external ear likely has acute mastoiditis, the most common suppurative complication of acute otitis media (AOM). The mastoid air cells are in continuity with the middle ear, allowing spread of the infection. In addition to the symptoms of fever and ear pain seen in AOM, infection of the mastoid causes erythema and tender swelling, which can result in outward and/or vertical displacement of the auricle. The tympanic membrane may show evidence of AOM (eg, erythema, bulging, perforation) or may not be visible due to swelling of the external auditory canal. acute otitis media (AOM) As with AOM, mastoiditis is most commonly seen in children age ≤2 and is commonly caused by Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. Pseudomonas aeruginosa has occasionally been implicated, especially in patients with recurrent infections or recent antibiotic use. Acute mastoiditis can often be diagnosed clinically. Imaging (eg, CT scan, MRI) is indicated if the diagnosis is unclear, if there is suspicion for further complications (eg, meningitis, neurologic deficits), if the child appears toxic, or if the condition does not respond to initial treatment. Treatment of mastoiditis requires intravenous antibiotic therapy. Drainage of the purulent material is also required. This can be achieved by tympanostomy (± ear tube placement) or mastoidectomy. (Choice B) Recurrent AOM is a risk factor for developing a cholesteatoma. However, a cholesteatoma typically presents with recurrent painless otorrhea. Examination would show a pearly white mass or a retraction pocket in the superior portion of the tympanic membrane. (Choice C) Necrotizing (malignant) otitis externa can present with severe ear pain and a swollen external auditory canal. However, it typically occurs in elderly patients with diabetes, and examination characteristically shows granulation tissue at the bony cartilaginous junction. (Choice D) Parotitis can present with fever and painful swelling around the ear; however, both preauricular and postauricular swelling would be present. It typically occurs in elderly postoperative patients rather than in young children. (Choice E) Perichondritis, an infection of the perichondrium, can present with a painful, erythematous ear. However, erythema and tenderness would be limited to the cartilaginous portions of the ear; the mastoid bone would not be affected. Educational objective: Acute mastoiditis is a complication of acute otitis media. It is characterized by fever, otalgia, and mastoid process inflammation with displacement of the auricle.

A 20-Month-Old Girl Is Brought to the Office Due to Fever