Boy, who often plays outside, presents with painful left ear
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A 5-year-old boy comes to your office with a painful left ear. The onset was 2 days earlier, with sudden, worsening pain and erythema of the pinna.
Additionally, his mother noted an unusual, white lesion at the superior end of the helix, at the junction of the scalp. His past medical history is that of a healthy, active, 5-year-old boy with lots of outdoor play activity, and his mother does not always see what he is doing. His immunizations are up to date, and he has never had an ear infection or any other problem with his ears until now.
The patient’s vital signs and examination are normal except for the chief complaint. His left ear reveals significant displacement of the auricle forward (Figure 1), with bright erythema and mild swelling of the pinna as well as the postauricular area (Figure 2), sparing the earlobe (Figure 3). On closer exam of the superior helix, the white, pustular-like lesion is seen just above an area that appeared to have some denuded skin, which may represent similar lesions that were scratched off (Figure 4) or other lesions that remain unexplained. There is diffuse tenderness throughout the area. The ear canals and tympanic membranes are both clear and normal. The white, pustular-like lesion was sterilely drained, revealing a small amount of whitish material, which was sent to the lab for Gram stain and culture.
What’s your diagnosis?
A. Cellulitis of the auricle
B. Fire ant sting
C. Mastoiditis
D. Perichondritis
Answer and discussion:
Both cellulitis and perichondritis are acceptable answers. Sparing of the earlobe is concerning for a deeper infection of the pinna. A superficial, simple cellulitis would not likely stop at the junction of the earlobe and the pinna. But it is not always clear. Perichondritis is an infection that usually results from some penetrating injury, such as a cosmetic piercing, traumatic accidents or other breaks in the skin, even an insect bite, especially with the help of scratching. If the earlobe is inflamed due to a piercing infection, it may be limited to the earlobe but could spread. If it is limited to the earlobe, one can safely say that there is no evidence of perichondritis. The perichondrium is the thin fibrinous tissue surrounding the cartilage of the pinna, providing the only source of nutrition. If damaged by advancing infection, it can damage the cartilage, leading a cosmetic deformity. The most common organisms infecting the pinna include Staphylococcus aureus, Pseudomonas aeruginosa and occasionally group A strep, which may be manifested as erysipelas. A good rule for empiric antimicrobial coverage is to select an anti-staph and an anti-pseudomonal combination. This will likely cover other less common possibilities as well. Ultimately, therapeutic de-escalation should be based on culture results. Any bulging should alert one to a possible abscess, in which case ENT should be consulted, as the pressure of an abscess could damage the tissues beyond repair. In this case, the culture of the pustule grew group A strep (Streptococcus pyogenes). One reasonable explanation as to the mechanism of this infection could have been that there were multiple insect bites that prompted scratching, thereby opening a port of entry for the organism colonizing the skin over the area.
Fire ants almost always leave multiple stings from a single or multiple ants, and almost always on the extremities (Figure 5). These stings usually bring the child running back into the house with pain. Additionally, secondary infections are so uncommon, I have never seen one, living most of my life in a state where fire ant stings are common. Also, I have never seen one anywhere other than the distal extremities, but I’m sure people have sat down on or near a fire ant bed and got stung near the contact area. Also, cattlemen, like my brother-in-law, will tell stories of a cow giving birth near a fire ant bed out in the pasture, which will soon cover the newborn calf and sting it to death. By nature, fire ants attack en masse and can do a lot of damage in a short period of time. Obviously, this did not fit the case in this vignette.
Mastoiditis would be expected to result in postauricular pain, erythema and swelling, causing the pinna (auricle) to be displaced forward. The patient presented had these findings, but with no history of past episodes of otitis media, and none associated with this current infection, mastoiditis is extremely unlikely.
Columnist comments
Fire ants are just one of the many summertime threats to children. As we all know, a child left in a hot car can be fatal in a matter of minutes. Wasp and bee stings and snake bites can also be life-threatening. Fortunately, fire ant stings are so painful, the victim does whatever it takes to get them off in a hurry. Also, we are lucky that these ants are not as big as those in the 1954 sci-fi thriller Them, when giant ants reigned terror in the New Mexico desert, eventually making their way to the Los Angeles drainage system, where they were cleared out by the Army using flame throwers. Seeing that movie on the big screen at 7 years of age, as well as the hero in The Incredible Shrinking Man doing battle with a giant spider at 10 years of age, left me with an ant/spider phobia that lives still today (much to my wife’s dismay, as she has to remove all spiders that get in the house). Don’t ever think that movies that young children see have no lasting effect. Be careful out there, and get your kids immunized.
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Brien is a member of the Healio Pediatrics and Infectious Disease News Editorial Boards, and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.