Otitis Media

Not Your Typical Case of Otitis Media

Danielle G. Hirsch, MD, MPH
Michelle Penque, MD
Brian H. Wrotniak, PhD
Richard D. Thomas, MD
Volume 15 - Issue 2 - February 2016

A brain CT with intravenous contrastA 6-year-old female presented to the emergency department with a 3-day history of fever, left-sided headache, difficulty sleeping, vomiting, and phonophobia with hyperacusis of her left ear. She was diagnosed with otitis media 1 day before and started on amoxicillin. 

During examination, her left tympanic membrane was occluded by firm cerumen that was unable to be removed due to pain. There was tenderness behind her left ear with erythema noted behind both pinnae. Her vital signs and the remainder of the physical examination were normal. The patient’s complete blood count was unremarkable.  

A brain CT with intravenous contrastA blood culture was obtained, as well as a computed tomography (CT) scan without contrast that revealed near-total opacification of the bilateral mastoid air cells. On the left side there was evidence of cortical discontinuity and intracranial air (Figure 1). 

A brain CT with intravenous (IV) contrast was then obtained and confirmed intracrainial air within an epidural abscess in the left posterior fossa measuring 3 cm × 0.8 cm, elevating the sigmoid sinus (Figure 2A). Outlined within the sigmoid sinus revealed a nonocclusive thrombus (Figure 2B). 

What caused this child’s headache and pain? 

(Answer and discussion on next page)

Answer: Acute mastoiditis

Bilateral tympanostomy tubes were placed along with drainage of the abscess, with a mastoidectomy. The patient received IV ceftriaxone and clindamycin for 4 weeks despite negative blood/abscess cultures and was loaded with heparin. She was transitioned to enoxaparin for discharge home and ultimately did well. 

Mastoid CT: coronal plane image demonstrating opacified air cells, erosion of superior mastoid cortex, and intracranial air.

Despite advances in antibiotic therapy, the most life-threatening complications of otitis media are intracranial, with incidence ranging from 0.13% to 1.97%, the majority occurring in developing countries.1,2 Early antibacterial treatment can mask the classically described signs and symptoms, making diagnosis difficult.2

Cranial imaging is the gold standard for diagnosing otogenic intracranial complications.1 Most commonly used is the CT scan without contrast to see bone changes, but it has poor sensitivity to assess a thrombus. Therefore, a CT scan with IV contrast or an enhanced magnetic resonance imaging scan should be obtained to increase sensitivity if a thrombus is suspected.3,4 

Epidural abscess is a less common complication of mastoiditis due to a spread by contiguity following bone destruction in coalescent mastoiditis adjacent to the dura.5,6 It can occur in the middle cranial fossa; however, the posterior fossa is more common.7 The patient is usually asymptomatic with lack of focal neurologic symptoms.6 Treatment comprises IV antibiotics and a mastoidectomy.6,8

Contrast-enhanced CT of the brain. (A) Coronal plane image demonstrating elevated enhancing dura (arrow), with underlying epidural abscess containing fluid and air, located over the mastoid surface. (B) Coronal plane image demonstrating nonenhancing thrombus (arrow) at the sigmoid sinus/internal jugular vein junction. High attenuation contrast around the medial margin and inferiorly indicates incompletely occlusive thrombus.An epidural abscess may lead to a sigmoid sinus thrombosis as a protective mechanism in an attempt to localize the infection; this is a rare and potentially life-threatening complication.5 The treatment is a mastoidectomy and early antibiotic therapy, but the approach to the thrombus is controversial.3,9 Some options include a thrombectomy with a jugular vein ligation or surgical clearance for infection drainage, and even more controversial is the use of heparin and oral anticoagulants.3,5 

Bacterial cultures obtained are negative approximately 50% of the time, likely due to the previous use of antibiotics.7,10,11 Of the cultures that grow, gram-negative bacteria are mostly reported, which would justify the use of a broad-spectrum antibiotic.7,10,11

Although rare, complications from otitis media can occur and require a comprehensive understanding of the etiologic presentation in order to best match appropriate imaging and treatment options to minimize potential intracranial complications.

Danielle G. Hirsch, MD, MPH, is a pediatric emergency medicine fellow at the University at Buffalo School of Medicine and Biomedical Sciences in Buffalo, New York.

Michelle Penque, MD, is a clinical assistant professor for UBMD Pediatrics, Division of Pediatric Emergency Medicine, at the University at Buffalo in Buffalo, New York. 

Brian H. Wrotniak, PhD, UBMD Pediatrics, Division of Pediatric Emergency Medicine at the University at Buffalo in Buffalo, New York.

Richard D. Thomas, MD, is the medical director for the Department of Radiology at Women and Children’s Hospital of Buffalo in Buffalo, New York. 

REFERENCES

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