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A 32-year-old male surfer with a history of recurrent childhood otitis media as well as adenoidectomy and tympanostomy tube placement presents to the emergency department with a complaint of progressive right ear pain that started 2 weeks ago. Four days ago, he had seen an otolaryngologist, who prescribed ciprofloxacin-hydrocortisone ear drops for a diagnosis of otitis externa. Two days after that, the patient was seen in the emergency department because the pain worsened despite treatment, and otitis externa was again diagnosed. Acetaminophen-codeine was added to his regimen of ibuprofen and the topical antibiotic. On this visit, he reports having constant, severe ear pain and headache despite analgesia. He denies having fever and vomiting but says he cannot hear in his right ear. He denies any other medical history, specifically a history of diabetes mellitus.

On physical examination, the patient appears well and has normal vital signs. In his left ear canal are moderate-sized canal exostoses; the left tympanic membrane appears normal. For the right ear, the outer ear canal is patent without notable narrowing, but a purulent, yellow-gray discharge obscures the tympanic membrane and inner canal. No substantial tenderness is noted with gentle traction of the pinna or with compression of the tragus. However, palpation of the temporal bone causes discomfort. No obvious periauricular swelling or mass is observed. The oropharynx is clear without trismus. No lymphadenopathy is noted on neck examination. Neurologic examination reveals no facial weakness, cranial nerve deficit, nystagmus, or cerebellar findings. The rest of the physical examination yields unremarkable findings. CT of the skull and brain is performed (see Image).

What is the diagnosis?

Answer

Mastoiditis: The CT scan demonstrates opacification of the mastoid air cells on the right side consistent with acute mastoiditis. Mastoiditis is a rare complication of otitis media that has become more infrequent since the advent of antibiotics. It involves a local spread of infection into the mastoid air cells in the temporal bone that eventually causes bony destruction.

Clinical manifestations of mastoiditis include decreased hearing, otalgia, otorrhea, tenderness, and erythema and swelling over the mastoid process that, when severe enough, may cause auricular protrusion. The condition is most common among young children, often in those who have had recurrent acute otitis media. Although this condition was classically thought to develop after prolonged acute otitis media or after an asymptomatic period after treatment, approximately one third of patients are symptomatic for <48 hours before diagnosis. The diagnosis is confirmed with CT, which demonstrates opacification of mastoid air cells and destruction of the bony cell walls.

Complications may include subperiosteal abscess, meningoencephalitis, subdural empyema or abscess, neck abscess (Bezold abscess), palsy of the seventh cranial nerve (Gradenigo syndrome), labyrinthitis, and venous sinus thrombosis. Organisms typically found on culture to be responsible include Streptococcus pneumoniae, Haemophilus influenza, and Streptococcus viridans. Gram-negative bacteria may occur in debilitated patients or patients with chronic infections. The differential diagnosis of mastoiditis includes otitis media, local cellulitis, posterior auricular lymphadenopathy secondary to local infection, and, in rare cases, rubella.

Treatment involves antibiotics, analgesics, and often surgical drainage. About one half to two thirds of patients respond to a 3- to 6-week course of intravenous antibiotics alone. The rest eventually require surgical intervention. Broad-spectrum penicillins, such as ampicillin-sulbactam or ticarcillin-clavulanate, are the recommended primary agents. Alternative antibiotics include second- or third-generation cephalosporins. All patients with mastoiditis should be admitted to the hospital for consultation with an otolaryngologist.

Link to further Information on:

For more information on mastoiditis, see the eMedicine articles Mastoiditis (within the Emergency Medicine specialty), Middle Ear, Mastoiditis (within the Otolaryngology and Facial Plastic Surgery specialty), and Mastoiditis (within the Pediatrics specialty).

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