What is the best course of action for a patient with protein S deficiency, hypertension, hyperlipidemia, and hypothyroidism presenting with soreness and swelling behind the right ear?

Immediate Evaluation for Mastoiditis

This patient requires urgent evaluation for acute mastoiditis, which presents as soreness and swelling over the mastoid bone (behind the ear) and represents a potentially serious complication requiring prompt imaging and possible surgical intervention. 1, 2

Initial Assessment

Critical Physical Examination Findings to Document

• Postauricular examination: Assess for erythema, swelling, and tenderness directly over the mastoid bone behind the right ear 2
• Pinna position: Look for anterior and inferior displacement of the pinna, which indicates mastoid inflammation 2
• Otoscopic examination: Remove any cerumen to visualize the tympanic membrane; document color, position (bulging vs. retracted), opacity, and mobility with pneumatic otoscopy 2
• Tragal tenderness test: Press on the tragus and pull the pinna to differentiate acute otitis externa from mastoiditis 1, 2
• Ear canal inspection: Evaluate for edema, erythema, debris, or purulent material that would suggest otitis externa 2

Key Historical Features

• Onset and duration: The one-month duration suggests a subacute or chronic process rather than acute bacterial mastoiditis 1, 2
• Associated symptoms: Ask specifically about hearing loss, otorrhea, vertigo, tinnitus, aural fullness, fever, and headache 2
• Recent ear infections: Determine if there was preceding acute otitis media or otitis externa 2

Differential Diagnosis

Primary Concern: Mastoiditis

• Postauricular swelling and tenderness over the mastoid bone are the hallmark features 2
• May occur with or without preceding acute otitis media 2

Alternative Diagnoses to Consider

Temporomandibular Joint (TMJ) Disorder: The most common cause of referred otalgia when the ear canal appears normal without middle ear disease 1

• Patients report pain radiating to the periauricular area and may have history of bruxism or gum chewing 1
• Tenderness over the affected TMJ with associated crepitus on examination 1
• Pain typically worsens with chewing 2

Acute Otitis Externa: Would present with tragal tenderness, canal edema, erythema, and debris 2

Referred Pain from Dental Pathology: Assess for dental caries, impacted molars, or recent dental procedures 1

Immediate Diagnostic Workup

Imaging

CT temporal bone without contrast is indicated if preauricular/postauricular swelling persists or clinical suspicion for mastoiditis exists 2

• Evaluate for mastoid air cell opacification, bony erosion, or abscess formation 2
• This is the definitive test to confirm or exclude mastoiditis 2

Audiometric Testing

Obtain audiometry as soon as possible (within 14 days) if hearing loss is suspected 3

• Perform Weber and Rinne tuning fork tests to differentiate conductive from sensorineural hearing loss 3, 2
• Formal audiogram confirms the diagnosis and establishes baseline 3

Management Algorithm

If Mastoiditis is Confirmed on CT

1. Urgent ENT referral for possible surgical intervention (mastoidectomy) 1
2. Intravenous antibiotics covering common pathogens (Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Pseudomonas aeruginosa) 2
3. Hospital admission for close monitoring and definitive management 2

If TMJ Disorder is Diagnosed (Normal Otoscopic Exam + TMJ Tenderness)

1. Analgesics: Prescribe acetaminophen or NSAIDs based on symptom severity for mild-moderate discomfort 1

   • Caution: Given this patient's hypertension and hyperlipidemia, NSAIDs should be used with caution due to cardiovascular risks 4
   • NSAIDs can lead to onset of new hypertension or worsening of preexisting hypertension 4
   • Monitor blood pressure closely during NSAID treatment 4

2. Muscle relaxants: Consider for masticatory muscle tension associated with bruxism 1

3. Physical therapy: Recommend jaw exercises and physical therapy for TMJ rehabilitation 1

4. Reassess in 2-4 weeks: If symptoms persist despite conservative management, refer to otolaryngology 1

If Acute Otitis Externa is Diagnosed (Tragal Tenderness + Canal Inflammation)

1. Topical antibiotics: Prescribe agents covering Pseudomonas aeruginosa and Staphylococcus aureus as first-line therapy 2
2. Avoid systemic antibiotics for uncomplicated acute otitis externa 2
3. Reassess in 48-72 hours to confirm clinical improvement 2

Critical Pitfalls to Avoid

Do Not Miss Serious Pathology

• Never treat ear pain without visualizing the tympanic membrane - this leads to misdiagnosis and inappropriate therapy 2
• Do not overlook malignancy: Older patients with persistent otalgia, normal ear examination, and history of tobacco/alcohol use require complete head and neck examination with visualization of mucosal surfaces 1
• Urgent ENT evaluation is necessary if cranial nerve deficits, facial paralysis, or severe headache develop 1

Medication Considerations in This Patient

Given protein S deficiency (thrombophilia): This patient is at increased risk for venous thromboembolism 5, 6

• Avoid prolonged immobilization during treatment 6
• Be aware that protein S deficiency predisposes to venous (not arterial) thrombosis, typically deep venous thrombosis, superficial thrombophlebitis, and pulmonary embolism 6

Given hypertension and hyperlipidemia: NSAIDs should be used cautiously 4

• NSAIDs increase risk of cardiovascular thrombotic events, myocardial infarction, and stroke 4
• Use the lowest effective dose for the shortest duration possible 4
• Monitor blood pressure closely during NSAID therapy 4

Given hypothyroidism: Ensure thyroid hormone replacement is optimized, as hypothyroidism is commonly associated with hyperlipidemia and hypertension 7, 8

When to Reassess or Refer

• Return for re-evaluation if true otalgia, otorrhea, or hearing loss emerges 1
• Otolaryngology referral is recommended if symptoms persist beyond 2-4 weeks despite conservative TMJ management 1
• Immediate ENT consultation if imaging confirms mastoiditis or if clinical deterioration occurs 1, 2