Acute Mastoiditis

Concerned that her 7-week-old daughter's left ear was far more prominent than the right one, the mother took the infant to the emergency department (ED) for evaluation. The swelling had begun 3 or 4 days earlier; the patient was otherwise asymptomatic.

Diffuse swelling, some superior but most posterior to the left ear, was noted on the left periauricular area. Neither increased temperature to touch nor redness was present.

No distinct mass was palpable. The patient's axillary temperature was 37°C (98.7°F). The left tympanic membrane could not be seen because of the distorted ear canal. Lymphadenopathy was diagnosed, and amoxicillin was given.

Robert P. Blereau, MD of Morgan City, La, reports that the patient had been delivered at 36 weeks' gestation. Shortly after birth, respiratory distress with end-expiratory grunting and tachypnea developed. Radiographic findings were consistent with surfactant deficiency.

Oxygen therapy was unsuccessful, and the patient was transported to a tertiary care center, where she was treated for 22 days for prematurity, respiratory distress, possible sepsis, and apnea of prematurity. Caffeine and multivitamins were prescribed at discharge. Until the postauricular swelling occurred, the child's course at home was uneventful; an apnea monitor recorded no apneic episodes.

After she was treated in the ED, the patient was referred back to the tertiary care center for evaluation by a pediatric ear, nose, and throat (ENT) specialist. A CT scan of the head revealed bilateral chronic otitis media and mastoiditis with external wall breakthrough and an adjacent subperiosteal inflammatory process or abscess on the left. An immediate left complete corticomastoidectomy for acute suppurative coalescent mastoiditis was performed. During surgery, a left mastoid subperiosteal and intramastoid abscess-which had ruptured through the outer cortex of the left mastoid portion of the temporal bone-was found along with dense granulation tissue of the entire left middle ear and mastoid cavity and below the temporalis muscle. Bilateral otitis media with thick purulent effusions in both middle ears required bilateral myringotomies with insertion of Armstrong tubes through the tympanic membranes.

Blood and cerebrospinal fluid cultures were negative. Culture of the mastoid pus grew Streptococcus pneumoniae moderately sensitive to penicillin, resistant to erythromycin, and sensitive to chloramphenicol, cefaclor, ceftriaxone, and cefotaxime.

Initial postoperative medications were intravenous ampicillin, gentamicin, and vancomycin; later, these were discontinued and replaced by intravenous azithromycin and ceftriaxone, followed by oral cefixime. The patient's postoperative course was complicated by respiratory syncytial virus pneumonia. She was discharged from the hospital in good condition 18 days after surgery.

Oral cefixime was continued at home for 1 month. Four months after the operation, the patient has had no evidence of ENT infection or of a recurrence of mastoiditis.

Dr Blereau points out that mastoiditis is rarely seen today-particularly in a 7-week-old patient. However, he emphasizes that the disease needs to be considered in the differential diagnosis of persons who present with clinical and CT findings similar to those of this patient.