My first plan of action (and what I told parents) was IV, labs, CT, admit, IV abx, ENT consult. I am aware of the possible complications, have seen venous cavernous sinus thrombosis, though have not seen a case of mastoiditis in several years now.
Radiology said no to the CT, too much radiation. Even suggested that a head CT would be less radiation (than temporal bone scan) and would still show the mastoids. Wanted ENT input.
ENT (older, quite experienced) said no need to CT, would not change management, would see first thing in am for tympanocentesis and/or PE tubes. Said all OM includes some mastoid involvement. Try IV abx and drainage 1st.
Hospitalist also uncomfortable with no CT, called ENT back, same response (after midnight by now).
IV Unasyn & Vanco started. WBC 30, CRP 7.7
This am PE tubes placed, MEF cultured, clinical appearance improved by afternoon.
Of note this child was seen the day before his ED visit with no signs of mastoiditis by PCP.
Parents said he looked fine that am, low grade fever, then when they picked him up from daycare his ear was sticking out and scalp red.
This was the happiest, most playful, most comfortable child I have ever seen with mastoiditis. He was blowing bubbles at me during the exam, no tenderness or warmth, just erythema and a markedly protruberant ear on exam. EAC erythema, edema and suppurative OM probably the most impressive signs of infection.
Blood, MEF and MRSA cultures pending.
It would be interesting to hear from our ENT colleagues.
Kathleen Goetz, MD
Swedish Pediatric Emergency Services
From: Darrell Looney [mailto:[log in to unmask]]
Sent: Friday, June 01, 2012 4:51 PM
To: Goetz, Kathleen; [log in to unmask]
Subject: RE: mastoiditis imaging
Would definitely image looking for any extension whether cutaneous or for intracranial changes. Concerned because of persistent symptoms despite antibiotics.
> Date: Fri, 1 Jun 2012 07:19:50 +0000
> From: [log in to unmask]
> Subject: mastoiditis imaging
> To: [log in to unmask]
> 9 month old healthy immunized child with 17 days OM. Treated with Amoxil x 7 days, cefdinir x 10 days, presents with protruding right ear, suppurative ROM, post auricular erythema, fever, otherwise well appearing.
> Would you image this child who has clinical mastoiditis?
> If so - CT?
> Has your practice changed due to increasing concerns about CT/radiation exposure in infants?
> Kathey Goetz
> Kathleen Goetz, MD
> Medical Director
> Swedish Pediatric Emergency Services
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