Unusually positioned abscesses of the head and neck following suppurative otitis media

Abstract

A 5-year-old boy presented to the authors' paediatric admissions unit with a sudden onset of swelling of his left temple. He had a 4-day history of fever and otalgia. He had been prescribed cefalexin by his GP the previous day for suspected acute otitis media. His mother described him waking from his afternoon nap when she noticed, for the first time, a swelling over his left temple. He had a history of two previously treated episodes of acute otitis media in the preceding year. On examination he was febrile with a temperature of 37.9°C. A tender, firm, non-erythematous swelling was present over his left temple and several left cervical lymph nodes were palpable. Otoscopy revealed bilaterally scarred tympanic membranes. Initial investigations revealed a white cell count of 31.2 × 109/litre with a neutrophilia of 27.5 × 109/litre and a C-reactive protein of 261 mg/litre. Intravenous cefuroxime was started to cover a suspected soft tissue infection. Skull radiographs showed no areas of osteolysis. Ultrasonography of the lump was reported as showing a small fluid collection beneath a soft tissue swelling overlying the left temple, separate to the skull vault. Inflammatory markers returned to normal levels after a few days of antibiotic treatment. However, the temporal swelling was slow to resolve and he developed difficulty in opening his jaw fully. The original diagnosis was reconsidered and the opinion of a paediatric otolaryngologist was sought. A diagnosis of an abscess deep to the temporalis muscle (Luc's abscess) secondary to chronic suppurative otitis media was made and intravenous metronidazole was commenced in addition to cefuroxime. Computed tomography scanning, performed under sedation, revealed an ipsilateral mastoiditis ith opacification of the mastoid air cells (Figure 1) and confirmed soft tissue thickening and a fluid collection overlying the left squamous temporal bone (Figure 2). Mastoid exploration and drainage were considered. However, as the swelling resolved completely and his clinical condition quickly improved, he was managed conservatively with a total of 2 weeks intravenous antibiotics.