A 6-year-old boy is brought to the emergency department with fever, worsening left ear pain, and swelling behind the ear for the past day. He was treated 10 days ago with oral antibiotics for acute otitis media but continued to have intermittent fevers. Past medical history is otherwise negative. His temperature is 39.2°C (102.6°F), and his other vital signs are within normal limits. On physical examination, the left postauricular area is erythematous, tender, and swollen, with protrusion of the auricle. Otoscopic examination reveals a bulging, erythematous tympanic membrane with purulent material.
Which of the following is the most appropriate next step in management?
The correct answer is:
B) High-dose intravenous antibiotics with otolaryngology consultation
This child’s presentation is consistent with acute mastoiditis, a serious complication of acute otitis media caused by spread of infection into the mastoid air cells. Key findings include postauricular swelling and erythema, protrusion of the auricle, persistent fever, and otoscopic evidence of middle ear infection despite prior antibiotic therapy. Management requires hospital admission, prompt initiation of high-dose intravenous antibiotics (typically covering Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus), and urgent otolaryngology consultation. Surgical intervention (e.g., mastoidectomy) may be required if there is abscess formation or failure to improve with antibiotics.
Answer choice A: CT scan of the temporal bone, is incorrect. Although CT imaging may be useful to assess for complications such as abscess or intracranial extension, treatment should not be delayed when clinical findings are classic for mastoiditis.
Answer choice C: Oral amoxicillin-clavulanate therapy, is incorrect. Oral antibiotics are inadequate for mastoiditis, which requires intravenous therapy due to the risk of rapid progression and intracranial spread.
Answer choice D: Reassurance and outpatient follow-up, is incorrect. Mastoiditis is a potentially life-threatening condition and cannot be managed expectantly.
Answer choice E: Tympanostomy tube placement alone, is incorrect. While tympanostomy tubes may help with drainage, they are not sufficient as monotherapy for an established mastoid infection.
Key Learning Point
Mastoiditis is a complication of acute otitis media characterized by postauricular swelling and auricle protrusion. Management requires urgent intravenous antibiotics and head and neck surgery (ear, nose and throat; ENT) consultation.
