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Agree with admission and abx adjustment. That would be the way to go. The CT however would be "academic" when viewed through a retro-spectroscope if it is negative because there would then be no change in management. Perhaps the literature already points in that direction, but my practice scenario in Central Illinois says I need to be a bit more aggressive because of patient follow up issues incase ENT were to say "send 'em to my office in the morning", as well as the fact that admissions for a child such as this would have to be to the Children's Hospital about 40 minutes to 1hour away (as the ambulance flies). This means I have to present sufficient evidence to convince my colleagues to get them to agree to the transfer etc.. The pediatric hospitalist will probably be more comfortable with the CT than without it even if it just characterizes mostly extracranial findings.


DLooneyMD

Date: Fri, 1 Jun 2012 20:41:10 -0700
From: [log in to unmask]
Subject: Re: mastoiditis imaging
To: [log in to unmask]; [log in to unmask]

Why not admit and treat with IV meds that actually cover the pathogens (clinda/unasyn/vanco/rocephin combination of those) and scan only if no improvement?  I do not think amoxyl or omnicef are great for this condition.  Also, I do not think an ENT will jump to operate on a well appearing child without a trial of IV meds, plus this should probably be treated as mastoiditis for weeks and weeks anyway.  Tymponostomy at some point with treat and allow for cultures.  IMHO your impression of "ill appearing" and not duration of sx or fever should dictate imaging.   So, unless the child is ill appearing or meningitic, CT is academic and you end up irradiating a child that is <1yr of age with no impact on treatment.
 
Michael Gorn
St Joseph's Hospital Medical Center
Paterson, NJ
 
  

--- On Fri, 6/1/12, Darrell Looney <[log in to unmask]> wrote:


From: Darrell Looney <[log in to unmask]>
Subject: Re: mastoiditis imaging
To: [log in to unmask]
Date: Friday, June 1, 2012, 7:50 PM


Would definitely image looking for any extension whether cutaneous or for intracranial changes. Concerned because of persistent symptoms despite antibiotics.

DLooney, MD

> 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
> Office:  206-386-3313   ED:  206-386-2573   Cell: 253-370-7571
>  
> 
>  
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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