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


  • 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



  • 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


  • 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?


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.
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