Case Study of the Week: Mastoiditis

I can tell that cough, cold and sniffle season is in full force by just a quick glance at the waiting room in my workplace.  During this season it is tempting to move quickly from patient to patient trying to keep wait times low and patients happy.  But, next time you diagnose otitis media, don't miss mastoiditis, a potentially serious complication.

Family Nurse Practitioners certainly treat a lot of otitis media.  In rare cases, especially in young children an immunocompromised individuals complications can develop.  Mastoiditis, infection of the mastoid bone of the skull located just behind the ear, is a potentially serious diagnosis and can lead to hearing loss, facial nerve palsy and abscess formation even an abscess extending intracranially.  Nurse practitioners must be able to make this diagnosis early in it's course to avoid complications. 

Case Presentation

A mother brings her 14 month-old son to your clinic as he has had fever, is pulling at his left ear and has been fussy.  His pain is worse at night and he has expereinced difficulty sleeping.  Some drainage from the affected ear has been noticed on the patient's pillow after sleeping.  The mother is concerned her son may have an ear infection.  He has no prior history of otitis media and is up to date on his immunizations.  

On exam, the patient is fussy and has a temperature of 101.0.  His left tympanic membrane is erythematous.  You note erythema and tenderness to the mastoid area behind the affected ear.  Based on this patient's presentation, you suspect mastoiditis and order a CBC, ESR and a CT scan of the temporal bone to confirm you diagnosis and determine extent of involvement.  The patient is admitted to the local Children's Hospital for IV antibiotics and consultation with otolaryngologist.

Management and Outcome

Acute mastoiditis without osteitis (bone inflammation) is managed medically with antibiotics.  IV antibiotics should be administered for at least 48 hours, longer if fever persists.  Then, oral antibiotics should be prescribed for at least 14 days.  Typically, the condition resolves completely within two weeks.  If pain, fever or tenderness persist for more than 48 hours, cultures must be obtained, a new antibiotic therapy initiated and a CT of the temporal bone obtained to evaluate for complications.  In cases of acute mastoiditis with osteitis, surgery in addition to antibiotics is usually required. Mastoidectomy is preformed to remove the infected mastoid air cells.

Discussion

Nurse practitioners must perform a thorough physical exam on patients of all ages presenting with ear pain.  Although rare, mastoiditis is a serious complication of otitis media and must not be missed.  For more complete information discussing diagnosis and treatment of mastoiditis, Medscape Reference has a great article discussing presentation, diagnosis and treatment.