3-year-old with a Fever and Headache

A 3-year-old female presented to the emergency department (ED) with fever of 104 F and headache for the previous three days. Her parents reported the child also complained of an earache and had been taking “around the clock” acetaminophen and ibuprofen for two days. The child has a prior history of frequent ear infections that “usually clear up with observation.” The entire family, including their daughter, had cough and congestion. She had no vomiting, diarrhea, or other GI complaints. In the ED, her temperature was 103.4 F, heart rate 172, respiratory rate 25.  The child appeared uncomfortable but nontoxic. Her Wispr digital otoscope exam is shown. The remainder of her HEENT examination revealed erythema and tenderness behind her left external ear which was mildly prominent relative to the right. Manipulation of the left ear did not elicit tenderness. She had mild nasal congestion. Her chest was clear to auscultation, and her neurologic examination was nonfocal.

Which of the following is the most appropriate next step?

A. Cross-sectional imaging of her temporal bone with CT or MRI
B. Intramuscular ceftriaxone
C. Prescribe high-dose amoxicillin for 10 days
D. Arrange follow-up with otolaryngology (ENT) for tympanostomy (ventilation) tube placement

The child’s history and physical exam are concerning for acute mastoiditis—she has an obviously abnormal tympanic membrane (TM) that is markedly bulging with complete loss of all bony landmarks (for reference, the location of the umbo is labeled). The white appearance is due to a purulent middle ear effusion consistent with acute otitis media (AOM). The external findings of acute mastoiditis include posterior auricular erythema and anterior displacement of the ear, indicating inflammatory changes within the mastoid air cells and adjacent soft tissue and skin. While antibiotics are indicated to treat the usual AOM pathogens, neither intramuscular ceftriaxone nor a course of oral amoxicillin are typically sufficient management when acute mastoiditis is suspected. Likewise, while an ENT evaluation is indicated, it should be conducted as an emergent consultation due to the serious complications associated with progression. When suspected, cross-sectional imaging to further evaluate for mastoid coalescence (destructive osteomyelitis of the mastoid air cells), subperiosteal abscess, extension into the cerebral sinuses with thrombophlebitis, intra-cranial abscess, and meningitis. Whether CT or MRI is utilized is often an institutional choice based on availability and preference.

This young patient's temporal bone CT revealed an area of bony destruction of the mastoid air cells with a small subperiosteal abscess. She was admitted to the hospital and managed with IV antibiotics as well as followed closely by the ENT service. Her symptoms improved markedly by day three and she was discharged home on an extended course of antibiotics.

Key Learning Points:

1. Suspect mastoiditis in children with AOM who have tenderness, erythema, or edema in the posterior auricular area or persistent headache and fever  
2.  Strict follow-up precautions when the watch-and-wait approach is taken in children with known AOM
3. Evaluation includes CT or MRI of the temporal bone to evaluate for coalescence or evidence of intracranial extension
4. Management includes IV antibiotics and potentially surgical debridement and anticoagulation

References:

Sahi D, Callender KD. Mastoiditis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560877/

Cassano P, Ciprandi G, Passali D. Acute mastoiditis in children. Acta Biomed. 2020 Feb 17;91(1-S):54-59. doi: 10.23750/abm.v91i1-S.9259. PMID: 32073562; PMCID: PMC7947742.