Hot Seat Case #25 Denouement: Ear pain after water park

The Case
by Naomi Hughes, Children's National

This was a case of an 11 year-old previously healthy girl with left ear pain. She had a CT done to evaluate for mastoiditis and subsequently developed a mild left eye ptosis. Click here to read the full case presentation. 

Thanks to Dave Mathison and Paul Mullan for your clinical reasoning and to Maybelle Kou for stepping up for her second go around on the Hot Seat and providing a well-reasoned differential. This case had several challenging aspects that our commenters elaborated on, particularly how to approach undifferentiated neurological symptoms.

Clinical Pearls
Click here to read comments in full.

“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).” –Dave Mathison, Children’s National

“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?” –Dave Mathison, Children's National

“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.” Paul Mullan, Children’s National

“New central (UMN) findings with a fever need imaging. MRI with and without contrast of head please.” –Paul Mullan, Children’s National

“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.” –Paul Mullan, Children’s National

Your Responses to the Questions
Which one of the following tests would you need THE MOST to determine your treatment and disposition plan?
 

Most people agreed with Paul's comment that some imaging was needed and most people chose the CT. No one cared about getting a monospot or rapid strep test.

After the CT, the patient develops a mild ptosis of the left eye and the parents wonder if this is related to the CT contrast.
How likely is it that this new finding of ptosis actually related to the CT contrast?
 

Most people thought it was unlikely and no one thought it was very likely. 

The CT is read as relatively unremarkable.
What do you want to do now?

About half of the audience wanted to admit the patient while about one quarter were comfortable with outpatient management. A slightly smaller quarter wanted to talk to neurology and let them make the call on disposition. No one was okay with doing nothing and nor did anyone want to just give benedryl.

The Hot Seat Response
by Maybelle Kou, Inova Fairfax

To 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 externa 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.

The Denouement
by Naomi Hughes, Children's National
The patient had a normal CBC (Wbc 6.4 Hb 12.4 plt 253 S 68% L 15% Mono 9% Eos 7.5%) and normal BMP. The patient was discharged after sending lyme titers and pcp notified to follow up titers and treat if positive.

Strep and monospot were not done. Borrellia Bogdorferi pcr negative, Lyme titers pending.

The patient returned to the ED 4 days after the initial presentation for worseing left sided facial paralysis and pain with difficulty swallowing and left sided facial flushing. The was CT repeated and showed increased mild mucosal thickening. There were no other new findings.

More titers sent (ebv, cmv, hsv, adeno, parvo– lyme is neg) ENT was consulted and they stated that the pt was okay to discharge with a 14 day course of steroids. The patient was admitted for repeat presentation and neurology was consulted. The patient had an inpatient MRI showing abnormalities of the seventh cranial nerve consistent with Bell’s Palsy. 

Editor's Note: This patient had two head CTs and an MRI along with a multitude of other tests before the diagnosis of Bell's Palsy was reached. It highlights the atypical features that remind us that medicine remains an art as much as it is a science. On a side note, it reminded me how much water parks can be in the summer.
The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations but is on leave until September. This week's case was guest edited by Cathy Chung, faculty at Fairfax. We welcome your commentary.