A 2-year-old boy is brought to the clinic by his parents due to worsening right ear pain. His mother states, "He started tugging at his ear 3 days ago and had a fever, but I could not take time off from work to bring him in." This morning, the pain increased, and his father notes that "his ear seems more prominent, like it's sticking out from his head." The patient has been less active than normal but has had no vomiting, diarrhea, or rash. He had an episode of acute otitis media 2 months ago that resolved with oral antibiotics. Immunizations are up to date, and he takes no daily medications. Temperature is 40 C (104 F), blood pressure is 100/40 mm Hg, pulse is 132/min, and respirations are 30/min. Examination shows a tired, irritable boy who screams with any attempt to examine his ear. Swelling, erythema, and tenderness to palpation are noted posterior to the right ear. Otoscopy reveals an erythematous and bulging tympanic membrane with loss of normal landmarks and light reflex.
CT scan of the temporal bones is obtained which reveals fluid in the mastoid air cells with erosion of bony septa. Which of the following is the most appropriate step in management?

Question

A 2-year-old boy is brought to the clinic by his parents due to worsening right ear pain.  His mother states, "He started tugging at his ear 3 days ago and had a fever, but I could not take time off from work to bring him in."  This morning, the pain increased, and his father notes that "his ear seems more prominent, like it's sticking out from his head."  The patient has been less active than normal but has had no vomiting, diarrhea, or rash.  He had an episode of acute otitis media 2 months ago that resolved with oral antibiotics.  Immunizations are up to date, and he takes no daily medications.  Temperature is 40 C (104 F), blood pressure is 100/40 mm Hg, pulse is 132/min, and respirations are 30/min.  Examination shows a tired, irritable boy who screams with any attempt to examine his ear.  Swelling, erythema, and tenderness to palpation are noted posterior to the right ear.  Otoscopy reveals an erythematous and bulging tympanic membrane with loss of normal landmarks and light reflex.
CT scan of the temporal bones is obtained which reveals fluid in the mastoid air cells with erosion of bony septa.  Which of the following is the most appropriate step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c12c_ecfb_8f63_31781e799747_MD0005_00 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. In these cases, CT scan shows destruction of the bony septa in the mastoid air cells, confirming the diagnosis of acute coalescent mastoiditis. Treatment of mastoiditis requires intravenous antibiotic therapy with activity against common upper respiratory pathogens (eg, Streptococcus pneumoniae), as well as Streptococcus pyogenes and Staphylococcus aureus. Expanded coverage for Pseudomonas (eg, cefepime) should be used if there is a history of recent antibiotic use. Drainage of the purulent material is also required. This can be achieved by tympanostomy (± ear tube placement) or mastoidectomy. Patients should be monitored to ensure that they do not develop more severe complications due to extracranial (eg, subperiosteal abscess, hearing loss) or intracranial (eg, meningitis, brain abscess) extension. (Choice A) Combination ototopical antibiotics and glucocorticoids would be appropriate treatment for otitis externa, but they do not appropriately treat acute mastoiditis. (Choice B) Meningitis is a possible complication of AOM or mastoiditis. Lumbar puncture and CSF culture would be obtained for diagnosis. However, this patient does not have clinical signs (eg, vomiting, nuchal rigidity) or radiographic evidence (eg, effacement of ventricles indicating increased intracranial pressure) of meningitis. (Choice D) Oral antibiotics would be an appropriate treatment for uncomplicated AOM. However, this patient's CT scan showing destruction of the bone is diagnostic of acute mastoiditis, which requires more aggressive treatment. (Choice E) Sinus surgery with nasal irrigation may be indicated for complications of acute sinusitis (eg, orbital cellulitis). However, mastoiditis is a complication of AOM rather than sinusitis because the mastoid air cells are in continuity with the middle ear, not the paranasal sinuses. orbital cellulitis Educational objective: Acute mastoiditis should be treated with intravenous antibiotic therapy and drainage of the purulent material in the middle ear either by tympanostomy (± ear tube placement) or mastoidectomy.

A 2-Year-Old Boy Is Brought to the Clinic by His