A 14-Year-Old Boy with Left Ear Pain

Abstract

14-year-old boy presented to the primary care offi ce with a 4-day history of left ear pain. He denied any history of fever or other associated symptoms. The primary care physician noted a thickened, red, and bulging left tympanic membrane, but the boy had an otherwise normal physical exam. He was diagnosed with acute left otitis media and treated with oral amoxicillin 1,500 mg by mouth twice daily. He returned 4 days later with a complaint of a 1-day history of subjective fever and increasing left ear pain. His oral temperature was 97.0°F in the offi ce. Physical exam revealed mild left postauricular edema and erythema, with no obvious blunting of the retroauricular sulcus. The left cheek was edematous. Exquisite tenderness was noted with manipulation of the left pinna and tragus and on palpation over the left mastoid, cheek, and neck. Otoscopic examination revealed the left auditory canal to be erythematous, very edematous, and tender, with a moderate amount of mucoid drainage. The left tympanic membrane could not be visualized because of obstructive edema of the canal. The left postauricular node was palpable, mobile, and tender, with no other palpable lymph nodes. The right ear exam was unremarkable, and the remainder of the exam was within normal limits. Differential diagnoses considered in this case were based on the chief complaint of ear and facial pain. Foreign body was unlikely because of the age of the patient and lack of reported incidence. Dental pathology was ruled out on the basis that oropharyngeal exam was normal, with abnormal exam of the external auditory canal and periauricular structures. Barotrauma was unlikely because the patient had not been fl ying or deepwater diving. Sinusitis was not diagnosed based on the lack of postnasal drainage, normal nasal exam, and lack of pain with palpation over frontal and maxillary sinuses or dependent head positioning. Otitis media and middle ear effusion could not be defi nitively ruled out because of the inability to visualize the tympanic membrane. Based on physical fi ndings, the patient was diagnosed with left otitis externa and possible mastoiditis. He was treated in the offi ce with 1,000 mg of ceftriaxone infused intravenously over