Mastoiditis and otogenic complications — branching viva

Opening question

Examiner: Take me through this child. What is the diagnosis, and what is your frame for managing it? ^[4]

Candidate: The diagnosis is acute mastoiditis. The fever, irritability, postauricular erythema, swelling and tenderness, the lost postauricular crease, and the pinna pushed downward and outward, in a child with a bulging erythematous tympanic membrane after an upper-respiratory infection, are the hallmark postauricular signs. My frame is to recognise this as a suppurative complication of acute otitis media that threatens hearing, the facial nerve and the brain: admit, take blood cultures, start broad-spectrum intravenous antibiotics, refer urgently to ear-nose-and-throat surgery, perform a myringotomy for the intact drum, and reassess at 48 hours. ^{[4] [5]}

Examiner: How do you distinguish mastoiditis from uncomplicated acute otitis media? ^[4]

Candidate: The mastoid air cells are continuous with the middle ear through the aditus ad antrum, so they are inflamed to some degree in most acute otitis media — that is why simple AOM can cause mastoid tenderness. The line is the postauricular change: oedema and erythema behind the ear, a lost postauricular crease, and a pinna pushed downward and outward. Those signs mean the mastoid is obstructed and suppurating, and they are the trigger for admission and intravenous antibiotics. A child with otalgia and fever but a normal postauricular region and pinna position has acute otitis media. ^{[4] [8]}