Clinical Review Lesson of the week

Life threatening complications after partially treated mastoiditis

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7405.41 (Published 03 July 2003) Cite this as: BMJ 2003;327:41
  1. Jemy Jose (jemyjose@yahoo.co.uk), specialist registrar1,
  2. Andrew P Coatesworth, consultant2,
  3. Richard Anthony, specialist registrar1,
  4. P Gerard Reilly, consultant2
  1. 1Department of Otolaryngology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX
  2. 2Department of Otolaryngology, York Hospital, Wigginton Road, York YO31 8HE
  1. Correspondence to: Mr J Jose, 109 Ainsty Road, Wetherby LS22 7FY
  • Accepted 25 February 2003

Introduction

The introduction of antibiotics reduced the incidence of mastoiditis after acute otitis media from 50% to 0.4%.1 2 However, mastoiditis still occurs, and partially treated mastoiditis can alter the clinical picture of resultant intracranial and extracranial complications by masking the classic symptoms. We present three such cases, the first two with lateral sinus thrombosis and the third with a Bezold's abscess. We emphasise the importance of heightened awareness of the changing presentation of complications of mastoiditis so that these life threatening conditions can be recognised and treated early.

Case reports

Case 1

A 12 year old boy presented with a three day history of left sided otalgia, with two days of left temporal and parietal headache, vomiting, and true vertigo. He had had no previous otological problems. He had been prescribed co-amoxiclav with a diagnosis of “ear infection.” On examination, he had low grade fever of 37.8°C. He had minor neck stiffness but no focal neurological signs and no papillo-oedema. The left tympanic membrane was red and bulging. There was no tenderness over the mastoid.

On admission the diagnosis was acute otitis media in the left ear with possible intracranial complication. He had a neutrophilia. He was started on intravenous cefotaxime and metronidazole, and contrast enhanced computed tomography was done. This did not show any evidence of intracranial complications, but there was opacification of the left middle ear and mastoid air cells. A myringotomy allowed pus to be discharged under pressure from the middle ear. Culture of the pus grew β …

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