What is the most appropriate treatment for a 6-year-old boy with suspected complicated ear infection, possibly mastoiditis, presenting with fever, ear pain, and postauricular erythema and swelling after recent antibiotic treatment for an ear infection?

Management of Suspected Mastoiditis in a 6-Year-Old Child

Emergency surgical drainage by an otolaryngologist is the most appropriate treatment for this child presenting with fever, ear pain, headache, and postauricular erythema and swelling after recent incomplete antibiotic treatment for an ear infection.

Clinical Assessment and Diagnosis

The clinical presentation strongly suggests acute mastoiditis, a serious complication of acute otitis media:

• Fever and ear pain after recent incomplete antibiotic treatment
• Right-sided headache
• Postauricular erythema and swelling (classic sign of mastoiditis)
• History of missed antibiotic doses for a recent ear infection

These findings indicate progression from uncomplicated otitis media to mastoiditis with possible subperiosteal abscess formation.

Treatment Algorithm

First-Line Management:

1. Emergency surgical consultation with otolaryngology

   • Immediate referral is necessary due to the presence of postauricular swelling and erythema, which indicates extension beyond the mastoid air cells 1
   • The presence of these signs after failed antibiotic therapy strongly suggests a subperiosteal abscess requiring surgical drainage

2. Initiate intravenous antibiotics while awaiting surgical evaluation

   • IV ceftriaxone at 50-75 mg/kg/day (not to exceed 2 grams daily) 2
   • Provides coverage against common pathogens including Streptococcus pneumoniae and other common otitis media pathogens

Surgical Management:

• Otolaryngologist will determine the appropriate surgical approach:
  • Myringotomy with or without tube placement
  • Drainage of subperiosteal abscess if present
  • Mastoidectomy if indicated by disease extent

Evidence Supporting This Approach

Multiple studies support the need for specialist surgical management in this case:

• Contemporary case series report that 22-93% of patients with acute mastoiditis require mastoidectomy, with the variation reflecting differences in clinical practice and disease severity 1

• In a review of 1,124 episodes of mastoiditis, the success rate of antibiotics alone was only 24.6%, while minor surgical procedures had an 87.7% success rate, and mastoidectomy had a 97% success rate 3

• A study of 69 cases of acute mastoiditis found that approximately one-third required surgical management by complete mastoidectomy, with subperiosteal abscess being the most common indication for surgery 4

Why Other Treatment Options Are Inadequate

1. Oral antibiotics alone: Inadequate given the child's presentation with signs of mastoiditis after already failing a course of oral antibiotics 1

2. Intravenous antibiotics alone: While IV antibiotics are necessary, they are insufficient without surgical evaluation in a patient with postauricular swelling and erythema 5

3. Emergency department incision and drainage: This approach is insufficient as proper surgical drainage requires specialized otolaryngologic expertise and equipment to assess the extent of disease and avoid complications 1

4. Outpatient referral to otolaryngology: Too delayed given the acute presentation and risk of intracranial complications 6

Potential Complications if Untreated or Inadequately Treated

• Intracranial complications (reported in 6.8% of acute mastoiditis cases) 6:
  • Sigmoid sinus thrombosis
  • Epidural abscess
  • Meningitis
  • Brain abscess

Key Clinical Pearls

• The presence of postauricular swelling and erythema in a child with recent ear infection is highly suggestive of mastoiditis and requires immediate specialist evaluation
• Failed or incomplete antibiotic therapy for otitis media increases the risk of progression to mastoiditis
• Persistent otalgia or otorrhea while on oral antibiotics with associated neurologic symptoms (like headache) are ominous signs suggestive of complications 6
• Negative cultures are common in mastoiditis (found in up to 50% of cases), especially after antibiotic treatment, and should not delay appropriate surgical management 6