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Case study

The importance of recognising mastoiditis in children

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Nurses need to be able to recognise signs of this serious complication of acute otitis media.

Citation: Paul S et al (2012) The importance of recognising mastoiditis in children. Nursing Times; 108: online issue 3.

Authors: Siba Prosad Paul is a specialty year 5 trainee in paediatrics, Great Western Hospital, Swindon, and St Richard’s Hospital, Chichester; Rachel Wilkinson is trainee advanced paediatric nurse practitioner, St Richard’s Hospital, Chichester.

Mastoiditis is an infection of the skull’s mastoid bone, which is located just behind the ear. It is a serious complication of acute otitis media (AOM), a common infection in children that is generally viral in origin and self-limiting in nature. In most children with AOM, symptoms resolve within 2-3 days (Hoberman et al, 2011; Thorne et al, 2009).

The other known complications of AOM are intracranial abscess, facial nerve paresis (partial paralysis) and sigmoid sinus thrombosis (Abdel-Aziz and El-Hoshy, 2010; Thorne et al, 2009; Scottish Intercollegiate Guidelines Network, 2003).

Treatment strategies

Before the advent of antibiotics, acute mastoiditis was the most common infectious condition needing hospital admission among infants and young children (Thorne et al, 2009). It is most commonly seen in preschool children aged less than four years (Abdel-Aziz and El-Hoshy, 2010).

With the introduction of stringent antibiotic guidelines, most countries generally follow a “wait and watch” approach to managing AOM (SIGN, 2003). Following this conservative strategy, some recent reports have suggested an increase in the incidence of mastoiditis in children; further studies are needed to establish the reason behind this increase (Thorne et al, 2009; National Institute for Health and Clinical Excellence, 2008; SIGN, 2003).

Mastoiditis presents with earache, discomfort, discharge, headache, loss of hearing, fever, redness and swelling behind the ear; the ear may stick out (Fig 1).

Presentation and management

Harry*, aged four months, previously healthy, presented unwell, with a 24-hour-history of fever up to 39°C and a swelling behind the left ear. He was reported to be up to date with childhood immunisations.

Initial observations showed a temperature of 38.6°C, a pulse rate of 172bpm, a respiratory rate of 44/min, saturations 99% in air and a central capillary refill time of two seconds. Harry was found to have an inflamed left tympanic membrane and the left pinna was pushed forward and outward with a tender swelling behind the ear. He did not have any meningism and was clinically stable. The rest of the systemic examination was normal.

The provisional diagnosis was left-sided mastoiditis secondary to left-sided AOM. In view of the clinical presentation and his age, Harry was admitted to the paediatric ward.

Ongoing management

Blood inflammatory markers were raised with a neutrophil count of 16.2 x 109/mm3 and a C-reactive protein of 57mg/L. The patient was started on intravenous (IV) co‑amoxiclav and continued on oral feeds.

He was referred to the regional paediatric ear, nose and throat services. A CT scan of the mastoid region confirmed left-sided mastoiditis with no intracranial involvement. A left cortical mastoidectomy with myringotomy was performed on the same day and IV antibiotics were continued for five days.

Progress

As Harry continued to improve, he was discharged home from the regional unit after five days with a course of oral antibiotics to complete. A review at the follow-up clinic showed he had recovered completely and his hearing test was normal.

Conclusion

This case illustrates the importance of being aware of this rare but serious complication following AOM in young children.

As there is a risk of intracranial involvement, a CT scan is necessary and early surgical intervention is associated with a good prognosis.

* The patient’s name has been changed

Key points

  • Acute otitis media (AOM) is common in infants and young children
  • Mastoiditis is a serious complication following AOM
  • The affected ear may be raised and pushed forward, with a tender swelling behind the ear
  • Suspected mastoiditis cases should be referred to ear, nose and throat services
  • Follow-up is needed after treatment, as well as a hearing check

 

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