Mastoiditis

You are the SpR on call from home. ENT SpR on call.  The paediatric ST2 asks for advice managing an 8 year old child in A+E with earache and swollen ear who has been brought in by his step father.  He is pyrexial and had two seizures. How would you proceed?

Preparation

Whilst taking call from the paediatric doctor: 

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  • Ask to ensure the patient is in a place of safety such as the paediatric resus bed.

  • Recognise urgency, there is a risk of shock, intracranial spread and this can be life threatening.

  • Advise that you will attend urgently

  • Ask for intravenous access and bloods - full blood count, urea and electrolytes, C reactive protein, liver function tests, coagulation screen, blood glucose, group and save and lactate. Consider blood cultures if septic.

  • Ask to contact ENT SHO to meet in A+E and to bring appropriate equipment e.g. otoscope

Initial Assessment and Simultaneous Resuscitation:

On arrival, manage the patient using the A to E approach according to the Advanced 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

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During the acute phase state remember to provide constant reassessment. 

Focused history and examination

History 

  • 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

 

Examination

  • Ear examination - use otoscope and microscope. 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 e.g. signs of cranial nerve V and VI palsy - diplopia on lateral gaze may indicate Gradenigo syndrome

Investigations and Definitive Management

Investigations

  • Bloods as above

  • If concerned about intracranial mastoiditis and intracranial extension - High resolution CT of brain and temporal bone

  • Swab the ear particularly if there is discharge

 

Management

The patient will need admission. It is useful to keep the patient nil by mouth initially in case the patient needs to go to theatre

If stable ​

  • Conservative - aural suction

  • Medical - antibiotic as per microbiology (most likely organisms Strep. pneumonia, H. influenza, Moroxella catarrhalis or viral e.g. RSV, influenza),  fluids, analgesia, topical ear drops e.g. sofradex

  • If no response, manage as an unstable

 

If unstable (e.g. obvious abscess, CT shows intracranial complications etc.)

  • Conservative - aural suction. 

  • Medical - IV antibiotic as per microbiology advice, fluids, analgesia, topical ear drops e.g. sofradex

  • Surgical - e.g. incision and drainage of abscess, cortical mastoid, grommet, neurosurgery

  • In this scenario, the patient has been brought in by his step father - who may not be able to consent unless they have parental guardianship. Make sure you are familiar with who can consent on behalf of a child.​

Remember to document your findings and management plan and inform the patient/parents.

 Escalation

Consider discussion with

  • Consultant

  • Paediatrics for medical optimisation 

  • Neurosurgery

  • Microbiology

  • MDT decision regarding surgery

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.
ENT, ST3, interview, course, resource, date
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