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.


PMHx: None

PSHx: None

Social: Goes to school. Has a brother, no one else has symptoms at home

Immunizations UTD


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

Respiratory: CTA

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.

CT Scan

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.

Next Steps

Antibiotics: Vanc, Flagyl, Ceftriaxone

Consults: Neurosurgery, ENT, ID

While admitted:

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

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

20% idiopathic

Diagnosis and Treatment

Take-Home Points