Intern Report Case 1.5

intern-report

Presented by Maria Pak, MD

HPI

An 11-year-old boy with a PMH of asthma and allergic rhinitis, presents to ED with the chief complaint of right ear pain with drainage and a fever.  Approximately five days prior to being seen in the ED, the patient had a runny nose and nasal congestion.  These symptoms eventually resolved.   However, for the past 2 days, he has been having watery discharge from his right ear, decreased appetite, ear pain, general malaise and subjective fevers.  The discharge worsened on the morning of admission, and his mother felt that he was more tired and not really acting like he normally does (eg more fatigued, not eating right, not as active).  No nausea/vomiting, headaches, neck stiffness, or changes in sensorium.

PMH: asthma, allergic rhinitis, otitis media, eczema
PSH: (Any?) none
FH: sickle cell trait, diabetes, cervical cancer
SH: lives primarily with mother and 3 siblings, and 1 nephew
Meds: albuterol prn, flovent prn, nasonex, loratadine prn
All: NKDA

Physical Exam

Vitals: T 37.1, P130, RR28, BP 121/85, Sat?
Gen: The child is awake, alert, answers questions appropriately and cooperating with the examination.  He is lying on the stretcher,  drowsy but arousable.  Appears to be well-nourished male in no acute distress.
HEENT: Normocephalic, atraumatic.  The neck is supple, with full range of motion and no adenopathy.  The pupils are equal, round, and reactive to light, external structures of the eyes are normal.  Examination of the ears shows an apparent outward displacement of the pinna of the right ear, with tenderness to palpation over the mastoid area on the right.  There is clear fluid coming out of the right ear.  The tympanic membrane on the right is intact, clear and gray, but appears dull.  The tympanic membrane on the left appears normal.  Mucus membranes are moist, but lips are dry.
CV: S1,S2, tachycardic, regular, no murmurs/rubs/gallops
Resp: CTAB, no wheezing/ronchi/rales
Abd: Nontender, nondistended, soft with no organomegaly/masses
Msk: FROM x 4,no tenderness bruising or swelling
Neuro: CN exam: EOMI, patient can close eyes/shrug shoulders/turn head against resistance, sensation intact on both sides of face, visual fields intact, no hearing loss in wither ear.  Strength 5/5 in all extremeties. Patient oriented to person, time, and place.  Gait is normal

Diagnostic Studies

CT: complete opacifaction of right mastoid air cells, middle ear and external auditory canal no evidence of bony destruction or remodeling, opacification of right external canal, lymphoid hypertrophy of adenoids

image2

CBC: wbc 11.1 (53% neutrophils), Hgb 13, plt 290.

Course in the ED
Patient was bloused with 20cc/kg of normal saline.  ENT was consulted, the on call resident recommended Ciprodex ear drops and parenteral clindamycin and ceftriaxone.  He was initially admitted to the PICU due to possible sinus thrombosis seen on CT.  This was later read as negative for thrombosis by a senior radiology attending.  He underwent a right myringotomy by ENT during his hospital stay and wound cultures grew MSSA.  He was treated with antibiotics for 7 days, and then was discharged with a PICC line to have 2 additional weeks of antibiotic therapy at home.

Questions:

1)    What is the most common intracranial complication arising from middle ear infections?
a.    Epidural abscess
b.    Subdural empyema
c.    Meningitis
d.    External carotid artery thrombosis
e.    Petrous apicitis

2)    Which of the following is correct regarding the treatment of acute mastoiditis?
a.    Patients should be made NPO and preoperative laboratory studies should be obtained immediately since the majority of cases require surgical intervention
b.    Antibiotic therapy should always include coverage for anaerobes
c.    In an afebrile patient with stable vital signs and no intracranial complications seen on imaging radiographs, ED discharge with PO antibiotics and close ENT follow-up is appropriate
d.    Initial therapy should include a third-generation cephalosporin or  chloramphenicol with a semisynthetic penicillin, with clindamycin as an option for penicillin allergic patients
e.    Administer topical antibiotics, PO challenge and follow-up with ENT

3)    Other than clinical examination, what is the next most useful diagnostic modality used to diagnose this condition?
a.    MRI
b.    Schuller view radiographs
c.    Myringotomy with tympanocentesis
d.    CT scan
e.    Blood cultures

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

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