with Maybelle Kuo, Inova Fairfax
The Case
On exam:
T 38.3 P 78 R 14 bp 111/61
General: Well appearing, nontoxic. Normal voice.
HEENT: Sclera clear EOMI PERRL Bilateral TMs clear canals clear but left tragus tender to manipulation and also with significant tenderness of mastoid on left. OP with mild erythema no exudate mild swelling left greater than right uvula midline. Dentition intact without tenderness to palpation. Some pain opening and closing mouth. No ear proptosis.
Bilateral lymphadenopathy submandibular lymphadenopathy >0.5 cm, tenderness on submandibular region on left.
Neck supple with from, no meningismus.
Cardiac /pulm/abd exam normal.
Cranial nerve intact, no focal deficits, normal gait.
Questions for you (click on "vote" to see what others said:
You decide to get a CT scan with contrast to rule out mastoiditis or soft tissue pathology in the neck. Two of the images below.
Now the patient has a new complaint of not being able to close her left eye completely and wonders if this could be a side effect of the contrast for CT. You evaluate and notice that she has mild ptosis of the left eye and maybe there is a little decreased movement of left side facial muscles when she smiles, but no asymmetry of the forehead unless you stare at her forehead for too long.
The resident reads the CT as positive for bilateral symmetric lymphadenopathy, tonsillitis, and adenoiditis but no evidence of drainable fluid collection or mastoiditis.
Click here to read the denouement of this case.
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series but she is on a well-deserved leave. During July, August, and September guest faculty from Children's National, Inova Fairfax, and Johns Hopkins will serve as case mentors. Cathy Chung, Inova Fairfax, edited this case.
Sounds like a chicken or egg problem......is there a primary problem with the ear that spread to the CNs, or is there a problem with the CNs that is manifesting as ear pain....
ReplyDeleteI think it's natural to start with the ear....but the normal ear exam excludes a malignant otitis externa, perichondritis or mastoiditis that could explain the lymphadenopathy etc.
So why would a patient have ear/jaw pain with no physical findings on ear exam? Time to flip the boat. Sounds like the V3 distribution of CN5....(trigeminal neuralgia). So prior to the ptosis i'd be thinking about an acute inflammatory process with a cranial neuropathy (aseptic meningitis, etc).
But the UMN lesion described throws that for a loop. I'm assuming that the ptosis with preserved forehead movements is hinting at an UMN lesion, right? Now we're localizing at/above the motor nuclei. This makes me think of a demyelinating CNS disease rather than an infection. Whenever there are multiple neurologic findings that are difficult to localize to one place I think of ADEM. If I was in the ED I would prioritize 1) MRI brain followed by 2) Google.
Water parks... Always a good time and probably one of the few places left where kids go "outside" AND remain unwatched by parents. Where there is adventure, there is a possibility for fantastic mechanisms of injury/pathology - any place where you've got out-of-shape kids running full speed on a wet surface with the sun in their eyes holding a foam mat in one hand, a rock candy stick in their mouth, and pushing the kids around them on old staircases, we've got job security.
ReplyDeleteThis is a long intro so you can tell this is not a slam dunk. A few principles I think that are important in this case:
a. Ear pain is the knee of the face. That is, often their is pain, but often it is referred from somewhere else. The normal ear canal and TM makes me put ear infection/mastoiditis lower on differential. The CT slice that we can see is mostly air and not pus/fluid in the mastoids, so that suggests less likely mastoiditis.
b. New central (UMN) findings with a fever need imaging. MRI with and without contrast of head please. Please page neuro as well. Doesn't sound like Lyme facial palsy as central not peripheral finding.
c. If you see something abnormal first and then something new abnormal later that wasn't there before, there's a decent chance that the first thing caused the second thing. On first exam, she had a good story for peritonsillar abscess with fever, odynophagia, trismus, asymmetric palatal findings. My first thought is that this pus swelled, caused referred pain (ear), and continues to swell and now has extended from that space into other spaces. The CT image of the neck shown is pretty low (~C3/C4) and PTA often seen higher (C1/C2) so maybe we're just looking at the wrong level (or maybe I at the wrong level of thinking, but that MRI and neuro will hopefully fill in my deficits). The thing I'm worried about most would be that this pus has spread upwards and is intracranial or around the cranial nerves.
How did the pus get in there? Back to that rock candy stick...
Hot Seat response
ReplyDeleteTo summarise the case:
11 yo female with 3 days history of ear pain, that began in her throat, and now extends behind her ear, with radiation to the jaw, now with fever and facial droop. Clinical signs of external otitis +/- mastoid cellulitis. CT that isn’t shockingly revealing.
Dave and Paul have already brought up some great points:
Malignant otitis external would usually be accompanied by physical or CT findings.
Lyme: must be considered in weird pain scenarios.
ADEM: she sounds too well, not really encephalopathic.
Lemierre’s: Child might be sicker in appearance?
Throw in the water park…. Naegleria fowleri (sp? Apologies) is probably not the case here, but could be considered. DOUBTFUL.
Other Parapharyngeal space infections? No CT evidence.
One that wasn’t mentioned (besides the wretched Amoeba) Ramsay Hunt (varicella zoster activationin CN VII). It may be too early to see lesions, but may present with tenderness of the tragus and mastoid, might explain “sore throat”, ptosis and the ear pain. (This can affect multiple cranial nerves, including glossopharyngeal). Might cause local lymphatic reaction prior to rash development too.
In terms of diagnostic tests: Consider MRI/MRA to look for inflammation/AVM, CRP and sed rate, CMV, Lyme and Zoster IgG titres (not super helpful). One should also not assume the patient is neither diabetic nor HIV positive.
One could empirically begin Acyclovir, though I might talk to a neurology and/or ID consultant and consider steroids. Depending on follow up and ability to take PO, she might be able to go home.
That’s all I can think of.
Maybelle KOU