Differential Diagnosis for a 4-year-old Boy with Bleeding and Tenderness Behind the Ear

• Single most likely diagnosis:
  • Hematoma of the ear (perichondral hematoma): This condition is a common cause of bleeding and tenderness behind the ear, especially in children who may have experienced trauma to the area, such as a fall or a blow to the ear. The hematoma forms between the cartilage of the ear and its covering perichondrium.
• Other Likely diagnoses:
  • Trauma to the mastoid area: Direct trauma to the area behind the ear can cause bleeding and tenderness due to injury of the skin, subcutaneous tissue, or even the mastoid bone itself.
  • Infection of the external ear (otitis externa): While more commonly associated with symptoms like itching and discharge, severe cases of otitis externa, especially if caused by more aggressive bacteria, can lead to significant pain and possibly bleeding if the infection is severe enough to cause tissue breakdown.
  • Basilar skull fracture: Though less common, a fracture in the base of the skull can present with bleeding from the ear, among other symptoms like cerebrospinal fluid leakage, due to the proximity of the ear to the skull base.
• Do Not Miss diagnoses:
  • Meningitis: Although less directly related to the symptoms of bleeding and tenderness behind the ear, in cases where there's suspicion of a basilar skull fracture, there's also a risk of meningitis, an infection of the protective membranes covering the brain and spinal cord. This condition is medical emergency.
  • Intracranial hemorrhage: Similar to meningitis, if the bleeding behind the ear is associated with a head injury, there's a possibility of an intracranial hemorrhage, which is bleeding within the brain or between the brain and the skull. This is a life-threatening condition requiring immediate medical attention.
• Rare diagnoses:
  • Relapsing polychondritis: A rare autoimmune disorder that can cause cartilage inflammation, leading to pain, redness, and swelling of the affected areas, including the ears. While it could potentially cause bleeding if the inflammation leads to tissue breakdown, it's a much less common condition.
  • Mastoiditis: An infection of the mastoid bone, located behind the ear. It can cause pain, swelling, and tenderness in the area and, in severe cases, might lead to complications that could result in bleeding, though this would be more of a secondary symptom.