AOE case study: A typical scenario

Often, as a pediatric otolaryngologist, I am called to the emergency department to evaluate a patient with severe ear pain. In a typical scenario, a 5-year-old child with a potential diagnosis of mastoiditis presents with pain in his right ear lasting for four or five days. His primary care physician, who treated him initially, diagnosed otitis media and prescribed a course of amoxicillin. The child’s pain worsened progressively over this period, so his parents brought him to the emergency department. His parents report that he may have had a low-grade fever, but they did not take the child’s temperature during this illness.

Zorik Spektor

The patient is afebrile and has a painful right ear. Upon examination of the child, the emergency department physician finds significant tenderness around the right ear, exudate from the ear canal and edema. She is unable to visualize the tympanic membrane because of impacted cerumen. Laboratory studies show a normal differential, except white blood cell count is slightly elevated to 12.7. The emergency department physician then requests a computed tomography scan of the right temporal bone, which shows opacification of the right mastoid bone and middle ear. The radiologist reports a potential diagnosis of right mastoiditis.

When I examine the patient, I see that the child is generally in good spirits, but he clearly has discomfort in the right ear. The parents are anxious and concerned. Upon examining the right ear canal, I find crusting around the meatus and serosanguinous discharge. The patient has tenderness in the periauricular area, especially in the area around the tragus, edema of the canal and erythema of the meatal area. Looking in the canal, I see that the canal is impacted with debris, and has exudate and cerumen, and I am unable to visualize the tympanic membrane.

During the examination, the patient complains of significant discomfort, and the parents are increasingly anxious. At this point, I ask the emergency department physician to give the patient pain medication, per protocol. After the patient calms, I can examine the canal better.

Diagnosis and treatment

The first step to completing the examination and making a diagnosis is to clear the debris obstructing the ear canal. As I clear the debris with suctioning, I see inflammation of the ear canal, and I can better visualize the tympanic membrane, which is dull. I note fluid in the middle ear, but no purulence. The skin of the ear canal is producing exudate, and there is significant edema. I evaluate the CT scan and find opacification of the right middle ear and mastoid air cells. However, there is no evidence of bony destruction or soft tissue abscess in the postauricular area. I then determine that the patient has external otitis rather than true mastoiditis.

To treat the patient, I first initiate ototopical therapy with a fluoroquinolone and steroid combination. The second important part of clinical treatment is pain management. Provided that the patient is not immunocompromised and does not have diabetes, I prescribe ear drops and pain medication, and send the child home with plans to follow up in the office in approximately three to four days.

When the patient returns to the office, his condition is dramatically improved. Inflammation has decreased, pain has subsided, and hearing has improved. New debris that has formed in the ear canal is once again removed with suctioning. When I visualize the tympanic membrane, I note some remaining inflammation and fluid in the middle ear, but the tympanic membrane appears to be in much better condition. I recommend that the patient continue the course of otic drops. At follow-up one week later, the patient’s condition is resolving and improving, even though there may be residual fluid in the middle ear. Results of another follow-up examination one month later are entirely normal.

Dr. Zorik Spektor is director of the Center for Pediatric ENT – Head and Neck Surgery in Boynton Beach, Florida. He is an assistant clinical professor in the Department of Otolaryngology at the University of Miami Miller School of Medicine and an affiliate clinical assistant professor of biomedical science at Florida Atlantic University in Boca Raton, Florida.

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