Overview
A 9-year-old boy presented with 5-day cough, ear pain, and rhinorrhea; assessment focused on differential diagnosis, clinical evaluation, and emergency management for suspected mastoiditis or complications of acute otitis media.
Presenting Complaint and History
- 5 days of cough, ear pain, and rhinorrhea reported.
- Family history includes paternal hay fever and maternal diabetes mellitus.
- Child has allergic rhinitis; allergy and drug history negative.
- Developmental problem present; vaccinations up to date.
Clinical Evaluation and Differential Diagnosis
- If ear pain only: consider acute otitis media (AOM).
- Drowsiness, tachycardia, fever (38.5°C+), and mastoid swelling suggest mastoiditis.
- Crackles/crepitations with cough and fever indicate possible pneumonia.
- Red tympanic membranes without respiratory symptoms likely AOM.
- Differential diagnoses: mastoiditis, acute/chronic otitis media, otitis media with effusion, external otitis, URTI, pharyngitis, sinusitis, tonsillitis, adenoid hypertrophy, foreign body aspiration, lower respiratory infection, pneumonia, asthma, meningitis, herpes zoster, malignancy, dental abscess, reflux, psychogenic causes.
History Taking and Assessment
- Use open-ended questions; confidentiality observed.
- Socrates approach for ear pain: location, onset, character, aggravating factors, associated symptoms.
- Assess cough and rhinorrhea: onset, progression, character, triggers, and associated symptoms (cyanosis, vomiting, activity limitation).
- Evaluate impact: school performance, eating/drinking, activity, sleep.
- Screen for associated symptoms: fever, chills, rash, irritability, dental or swallowing issues, sleep issues, snoring, breathing difficulty, urinary symptoms.
- Assess for asthma, neglect/abuse, and injury risk.
Physical Examination
- Share findings with supervisor; ensure consent and privacy.
- General assessment: hydration, alertness, interaction, respiratory distress.
- Vitals: heart rate, respiratory rate, temperature, O2 saturation, growth parameters.
- ENT exam: skin changes, swelling, discharge, redness, fluctuation, otoscopic inspection, tympanic membrane evaluation, whisper test.
- Nasal and throat exam for foreign bodies, infection, and lymphadenopathy.
Case Management
- Emergency if drowsiness, high fever, mastoid swelling, dehydration present.
- Transfer to treatment room with supervision, call emergency services (000).
- Explain to parents: infection spread from ear to surrounding tissue (mastoiditis), risk of systemic spread.
- Hospital management: secure IV access, draw blood, IV hydration (20 ml/kg NS), antipyretic (paracetamol 15 mg/kg), oxygen if low saturation, start antibiotics (ceftriaxone, flucloxacillin), refer to ED.
- Hospital investigations: sepsis work-up, CXR, full blood count, ESR, CRP, renal/liver function, blood cultures, urine analysis/culture.
Post-Hospital and Follow-Up Care
- Monitor child until ambulance arrives; reassure parents.
- After discharge: review discharge letter, confirm diagnosis and medications, check for new symptoms, provide safety netting.
- Advise on hygiene, avoiding smoking, keeping ears dry, and no swimming for a week.
Pharmacological and Supportive Management
- Mastoiditis: 5 days IV antibiotics (ceftriaxone, flucloxacillin), then 7 days oral amoxicillin.
- AOM: paracetamol unless specific indications for antibiotics (age <6 months, perforation, bilateral, recurrent, ongoing pain, Aboriginal, cochlear implant, immunosuppression).
- If antibiotics given, review after 48 hours; perforation—review after 2 weeks, no swimming during this period.
Recommendations / Advice
- Avoid exposing child to smoke and ill contacts.
- Maintain hand hygiene and ear care (no cotton swabs, no swimming one week).
- Ensure vaccination is up to date.
- Use analgesics after checking for contraindications and allergies.