Clinical Case 2
Author: Dr. Melodie Keshani
Patient is an 8-year-old female with no PMHx who presents today for bilateral ear pain. Right ear hurts more than the left. Patient was prescribed Cefdinir for AOM earlier in the week. Patient's mother noticed episodes of diarrhea and vomiting so she took patient back to pediatrician. Pediatrician changed Cefdinir to Ciprodex. No fever, sore throat, congestion, abdominal pain, or congestion.
Social: Goes to school. Has a brother, no one else has symptoms at home
Temp: 97.5, BP: 110/68, HR: 106, RR: 24, O2 sat: 100%
General: No acute distress. Active. Smiling. Nontoxic
HEENT: Atraumatic. Normocephalic.
Left tympanic membrane: Normal. No mastoid tenderness. No discharge.
Right tympanic membrane: Unable to visualize due to debris. No mastoid tenderness. No discharge.
No pain with manipulation of pinna bilaterally. No overlying cellulitis
No pharyngeal erythema/exudates. No trismus.
CV: Regular rate and rhythm. No murmurs
Abdomen: Nontender, no guarding or rebound
Skin: No rashes
Neuro: A&Ox3. No extremity weakness
While patient was in the ED, she spiked a temp of 102 degrees. Mom notes she has been giving patient Tylenol + Ibuprofen around the clock for her pain.
1. Near complete opacification of the right mastoid air cells consistent with mastoiditis. No underlying bony erosion.
2. There is a 2.9 cm collection containing a focus of gas with peripheral rim enhancement adjacent to the right temporal bone likely representing an epidural abscess.
Antibiotics: Vanc, Flagyl, Ceftriaxone
Consults: Neurosurgery, ENT, ID
Right temporal burr hole for evacuation of epidural abscess
Culture from abscess + for S. pneumo
ENT: right myringotomy and tube placement
Mastoiditis in Pediatrics
Acute otitis media is associated with some degree of mastoid inflammation
A serious sequelae of acute otitis media
Classically: tenderness, erythema, edema or fluctuance over mastoid
Acute: <1 month
Chronic: > 1 month, hearing loss, drainage
Subacute/Masked: Inadequate tx
Diagnosis and Treatment
S. Pneumoniae is most common organism
Imaging: CT scan of temporal bone
Treatment: Tympanocentesis, Myringotomy, Tympanostomy tube, Mastoidectomy
If no history of otitis media: Vanc
If antibiotic use over the last 6 months: Vanc + Ceftazidime, Cefepime or Zosyn
60-87% improved without surgical interventions
Epidural Abscess in Pediatrics
0.5 per 100,000 children annually
Predisposing factors make up 80% of cases of brain abscess
30-50% stem from contiguous focus of infection (OM, mastoiditis, sinusitis, orbital cellulitis)
10% disruption of natural barriers
10% immunosuppressive conditions
Location of abscess depends on source of infection
Classic picture: fever (50%), headache (60%), focal neurologic deficits (25% seizures)
Diagnosis and Treatment
Cranial imaging: classic ring-enhancing with necrotic center
Aspiration via burr hole > craniotomy
Excision of entire abscess performed in > 2.5 cm or symptomatic patients
Third gen cephalosporin + metronidazole (+/- vanc)
Just because they were treated with antibiotics, doesn’t mean the infection is gone
S. Pneumo is likely your culprit
Trust no one...especially kids
Geoffrey A. Weinberg; Brain Abscess. Pediatr Rev May 2018; 39 (5): 270–272. https://doi-org.proxy.cc.uic.edu/10.1542/pir.2017-0147
Richard Kynion; Mastoiditis. Pediatr Rev May 2018; 39 (5): 267–269. https://doi.org/10.1542/pir.2017-0128
Rivera K, Truckner R, Furiato A, Martinez S. The Diagnostic Challenge of the Pediatric Brain Abscess. Cureus. 2021 Jun 2;13(6):e15402. doi: 10.7759/cureus.15402. PMID: 34104611; PMCID: PMC8174389.