Mastoiditis

You are the ENT CT1 on call.  The paediatric ST2 asks for advice managing an 8 year old child on CAU with earache and swollen ear who has been brought in by his step-father.  He is pyrexial and has had two seizures. How would you proceed?

Example answer

In this scenario I would be most worried about a possible mastoiditis and I would attend to see this patient immediately. I would perform an initial assessment and stabilisation of the child, take a focused history and examine the child, then put in place an initial management plan and inform my registrar.

Initial Assessment and Simultaneous Resuscitation

​On arrival, manage the patient using the A to E approach according to the Paediatric Life Support algorithm.

  • Airway

  • Breathing - O2 saturations, work of breathing - intercostal recession, use of accessory muscles - if any concerns give oxygen

  • Circulation - pulse, blood pressure, central and peripheral capillary refill time, urine output - consider catheterisation, IV access and bloods as above. 

    • Fluid bolus - Paediatrics give 20ml/kg of crystalloid solution (not dextrose)

  • Disability - AVPU, pupillary response, blood glucose

  • Exposure - look for signs of shock, evidence of meningism e.g. rash, nuchal rigidity GCS, pupils, BM, temperature

​​

During the acute phase state remember to provide constant reassessment. 

Focused history and examination

History 

  • Ear symptoms - otalgia/discharge/itch/vertigo/tinnitus/hearing loss/facial nerve palsy/headaches​

  • Neurological symptoms - vertigo/facial nerve/taste, seizures, headache, neck stiffness

  • General systemic symptoms - weight loss, fatigue, night sweats, fever

  • If the child is young there may be non specific signs e.g. pulling at ear, reduced feeding, irritability, v​omiting, clumsiness

  • AMPL- allergies/ medications including vaccination history/ past medical history including perinatal history, history of recurred acute otitis media, previous surgery/ last meal

  • Family history

 

Examination

  • Ear examination - use otoscope. Look for post-auricular swelling - tender to palpate, displaced pinna pushed anteriorly and inferiorly, loss of post-auricular skin crease, sign of subperiosteal abscess, discharge, bulging, erythematous tympanic membrane

  • Nose and throat examination

  • Full neurological assessment and cranial nerves 

Investigations and Definitive Management

Investigations

  • Bloods as above

  • Swab the ear particularly if there is discharge

  • I would discuss with the ENT registrar to review whether high resolution CT of brain and temporal bones is indicated

 

Q.1 What are the indications for a CT scan in acute mastoiditis?

  • Focal neurology

  • Meningism

  • Seizure

  • Swinging pyrexia

  • Severe sepsis/septic shock

  • Failure to improve with 24 hours IV antibiotics

Q.2 How would you manage this patient?

Immediate management

If stable ​

​​

  • Admit under joint care with paediatrics

  • Aural suction

  • Medical - antibiotic as per microbiology

  • IV fluids

  • Analgesia according to WHP ladder

  • Topical antibiotic ear drops e.g. sofradex

  • Keep nil by mouth

  • ENT Registrar review

  • Document

  • If no response in 24 hours or large abscess found on CT, manage as unstable​

 

If unstable (e.g. obvious abscess, CT shows intracranial complications etc.)

​​

  • Surgical - e.g. incision and drainage of abscess, cortical mastoid, grommet, neurosurgery

  • Inform emergency theatres, paediatric anaesthetist

  • Keep parents/legal guardians informed

  • Document​​

Q.3 What are some complications of acute otitis media?

 Escalation

Consider discussion with

  • ENT Registrar

  • Paediatrics for medical optimisation 

  • Neurosurgery

  • Microbiology

Useful Resources

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
core surgical training interview

© 2017-2018 BJK LTD

 

 

.Referral scheme

In collaboration with:

WWW.ENT-GURU.COM