What is the best course of action for a 2-year-old patient who has been pulling at her ear for 1 week and now has swelling along her jaw line on the affected side?

Immediate Same-Day Evaluation Required

This 2-year-old requires same-day medical evaluation, not a next-day appointment, due to the new-onset jaw swelling which raises concern for acute mastoiditis—a serious complication of otitis media that can progress rapidly and requires urgent assessment and treatment. 1, 2

Why This Cannot Wait Until Tomorrow

• Acute mastoiditis develops when infection spreads from the middle ear to the mastoid bone, presenting as swelling along the jawline/postauricular area, and represents a potentially serious complication requiring prompt intervention 1
• The one-week history of ear pulling followed by new swelling suggests progression from possible acute otitis media (AOM) to a complication 1, 2
• Contemporary data shows that 33% to 81% of patients with acute mastoiditis had been on antibiotics prior to admission, meaning even if this child were already being treated, the complication can still develop 1

Immediate Clinical Assessment Needed

The child requires urgent examination to determine:

• Presence of postauricular/mastoid swelling, erythema, warmth, or tenderness (classic signs of acute mastoiditis) 1
• Protrusion of the auricle (ear pushed forward/outward by mastoid swelling) 1
• Tympanic membrane findings: bulging, erythema, perforation with otorrhea, or middle ear effusion using pneumatic otoscopy 1, 2
• Fever, irritability, or systemic symptoms that would indicate more severe disease 1, 2
• Neurologic status to rule out intracranial complications 1

Management Algorithm Based on Findings

If Acute Mastoiditis is Confirmed:

• Immediate referral to emergency department or otolaryngology for consideration of IV antibiotics, possible CT imaging, and potential surgical intervention 1
• Treatment options range from IV antibiotics alone (10% of cases) to IV antibiotics with myringotomy (68% of cases) to mastoidectomy (22% of cases) depending on severity 1
• Streptococcus pneumoniae remains the most common causative organism despite pneumococcal vaccination 1

If Uncomplicated AOM Without Mastoiditis:

• At age 2 years, immediate antibiotics are indicated if the child has severe AOM (moderate-to-severe otalgia, fever ≥39°C) or bilateral AOM 1, 2
• High-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 10 days is first-line therapy 1, 2
• If amoxicillin was used in the previous 30 days or if there is purulent conjunctivitis, use amoxicillin-clavulanate instead 1, 2
• Pain management with acetaminophen or ibuprofen is essential and should be started immediately 1, 2

If Mild Unilateral AOM:

• Watchful waiting with close follow-up in 48-72 hours is an option for children ≥2 years with nonsevere, unilateral AOM 1
• However, given the one-week duration and new swelling, this scenario is unlikely

Critical Pitfalls to Avoid

• Never delay evaluation when new swelling appears after ear symptoms, as mastoiditis can progress to subperiosteal abscess, intracranial extension, or sepsis 1
• Do not assume the swelling is just a "swollen lymph node" without proper examination—postauricular swelling in the context of ear symptoms is mastoiditis until proven otherwise 1
• Avoid prescribing antibiotics over the phone without examination, as proper diagnosis requires visualization of the tympanic membrane and assessment for complications 1, 2
• Clinical improvement should occur within 48-72 hours of appropriate antibiotic therapy; if not, the child requires re-evaluation for treatment failure or complications 1

Follow-Up Requirements

• If antibiotics are started, re-evaluate at 48-72 hours to ensure clinical improvement (decreased fever, improved irritability, normalized eating/sleeping) 1
• If symptoms persist or worsen despite appropriate antibiotics, switch to amoxicillin-clavulanate or consider intramuscular ceftriaxone 1
• Tympanocentesis with culture should be considered if multiple antibiotic regimens fail 1