What should I monitor in a child with bruising after hitting the mastoid process?

Monitoring a Child with Mastoid Process Bruising After Fall

Monitor for signs of intracranial complications including altered mental status, persistent headache, vomiting, cranial nerve deficits, and signs of increased intracranial pressure, as mastoid trauma can lead to serious complications such as sigmoid sinus thrombosis, intracranial abscess, or meningitis. 1, 2, 3

Immediate Clinical Assessment

Neurological Monitoring

• Watch for altered mental status, persistent or worsening headache, repeated vomiting, seizures, or focal neurological deficits - these indicate potential intracranial complications requiring urgent imaging 4, 2
• Monitor for cranial nerve palsies, particularly facial nerve involvement, which occurs in approximately 11% of complicated mastoiditis cases 1
• Assess for signs of increased intracranial pressure including bulging fontanelle (if infant), papilledema, or deteriorating consciousness 2, 3

Local Examination Findings

• Examine for postauricular swelling, erythema, or fluctuance suggesting subperiosteal abscess, which occurs in approximately 7% of mastoiditis cases 1, 3
• Check for ear drainage, hearing changes, or persistent ear pain 1, 2
• Document the bruising pattern and location carefully, as the mastoid/ear area is a concerning location for abuse evaluation 4

Age-Specific Considerations for Abuse Evaluation

For Children Under 12 Months

A skeletal survey is necessary for any child under 12 months with bruising to the ear area, regardless of the reported mechanism, as bruising in this location has high specificity for abuse. 4

For Children 12-24 Months

• Skeletal survey appropriateness depends on additional factors including developmental stage, consistency of history with injury pattern, and presence of other concerning features 4
• Children ≥12 months with nonpatterned bruising on bony prominences may not require skeletal survey if the history is consistent 4

Critical Pitfall

The mastoid process is technically a bony prominence, but the ear area is specifically identified as a high-risk location for abuse that necessitates heightened scrutiny regardless of age under 24 months 4. The history of "falling onto a chair" must be carefully evaluated for consistency with the injury pattern and the child's developmental capabilities.

Bleeding Disorder Evaluation

When to Consider Laboratory Testing

• Obtain complete blood count, PT, aPTT, and peripheral blood smear if the bruising is disproportionate to the reported trauma, there are multiple bruises in unusual locations, or there is a personal/family history of bleeding symptoms 4, 5, 6
• Document any history of excessive bleeding after circumcision, dental procedures, or prior surgeries 4, 5
• Review all medications including NSAIDs, anticoagulants, and alternative therapies that may affect bleeding 4, 5

Important Caveat

Do not delay evaluation for intracranial complications or abuse assessment while pursuing bleeding disorder workup - these evaluations should occur simultaneously if both are indicated 4

Indications for Urgent Imaging

High-Risk Features Requiring CT Head

• Any altered mental status, persistent vomiting, severe or worsening headache, or focal neurological signs 4, 2
• Signs of mastoiditis including postauricular swelling, erythema, or ear drainage with systemic symptoms 1, 2, 3
• Age under 2 years with concerning mechanism or inconsistent history, per PECARN criteria 4

Mastoiditis-Specific Complications

Intracranial complications occur in approximately 12% of pediatric mastoiditis cases and include 1, 2, 3:

• Sigmoid sinus thrombosis (5.3% of cases) - presents with headache, altered mental status, or signs of increased intracranial pressure
• Intracranial abscess (3.9% of cases) - presents with focal neurological deficits, seizures, or altered consciousness
• Meningitis (0.3% of cases) - presents with fever, neck stiffness, altered mental status

Children with intracranial complications have significantly longer hospital stays and higher morbidity, making early recognition critical. 3

Follow-Up Monitoring

• Reassess neurological status every 4-6 hours for the first 24 hours if discharged home 4
• Return immediately for any new or worsening symptoms including headache, vomiting, confusion, vision changes, or seizures 4, 2
• Follow up within 24-48 hours to reassess bruising evolution and ensure no delayed complications 7
• Document bruising with photographs if there is any concern for non-accidental trauma 4