Visual Journal of Emergency Medicine 21 (2020) 100889

Contents lists available at ScienceDirect

Visual Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/visj

Visual Case Discussion

An outstanding ear – otitis externa with cellulitis versus mastoiditis T

Sydney Beatty, Glenn Isaacson
⁎

From the Departments of Otolaryngology – Head & Neck Surgery and Pediatrics, Lewis Katz School of Medicine at Temple University, 1077 Rydal Road, Suite 201, 19046
Rydal, PA, USA

ARTICLE INFO

Keywords:
Acute otitis media
Computed tomography
Mastoiditis
Otitis externa
Pneumatic otoscopy

1. Case
A 14-year-old boy presented to the Emergency Department with a 3-
day history of left-sided ear pain and one day of fever to 38.2C. He had
been swimming in a fresh water pond for most of the summer. The
physician assistant who saw him noted a protruding left pinna with
erythema and edema in the postauricular crease. (Fig. 1) There was
pain on movement of the pinna and the ear canal was narrowed. The
team ordered a CT of the temporal bones to rule-out mastoiditis. The
report came back, “marked edema of the left external auditory canal
with mucosal thickening of the middle ear and a few mastoid air cells –
consistent with early mastoiditis”. (Fig. 2)
When the otolaryngology resident arrived, she examined the teen-
ager and cleaned the ear. After removal of canal debris, it was possible
to see the tympanic membrane. The ear canal and ear drum were
covered with purulent exudate. (Fig. 3) The tympanic membrane was
mobile on pneumatic otoscopy. After discussion with her attending, the
resident placed an ear wick, and began treatment with topical cipro-
floxacin and oral amoxicillin-clavulanate. Follow-up was arranged for
the next day.
2. Discussion
Acute otitis externa (OE) with postauricular cellulitis and acute
otitis media (AOM) with coalescent mastoiditis can each present with
ear pain, fever, postauricular inflammation and a protruding pinna. It is
important to distinguish between these two medical emergencies as
their causative organisms, treatments and prognoses are different. OE
with cellulitis is more likely to be found in older children (>7 years)
and in the summer following lengthy water exposures. It affects the skin
of the ear canal with secondary involvement of the tympanic membrane
and periauricular subcutaneous soft tissues. Staphylococcus aureus and
Pseudomonas aeruginosa are the pathogens in most cases1.
AOM with coalescent mastoiditis occurs in younger children, in the
cold season, and usually several days into an upper respiratory infec-
tion. AOM is an infection of the middle ear and mastoid air cells rather
than skin and skin structures. AOM causes inflammation of the ear
canal and the postauricular soft tissues when bacterial toxins break
down bony partitions with direct extension of infection.2 Streptococcus
pneumonia, group A streptococci and Staphylococcus aureus are most
often recovered from the middle ear or mastoid.
Visualization of the tympanic membrane is key in distinguishing
these two entities on physical examination. This can be difficult when
the canal is swollen or filled with debris. In OE there is diffuse edema
and purulence involving the ear canal and surface of the tympanic
membrane. (Fig. 3) As the middle ear is spared, the eardrum is mobile
on pneumatic otoscopy. In AOM with mastoiditis, edema is usually
limited to the posterior ear canal. The ear drum is typically bulging and
immobile on pneumatic otoscopy.
While imaging is not needed in clear cases of OE with cellulitis,
there are settings where computed tomography can be helpful. When
the tympanic membrane cannot be seen well, especially in an ill
younger child, axial sections through the middle ear and mastoid can
rule-in or rule-out coalescent mastoiditis.3 It should be noted that
edema of the tympanic membrane and opacification of a few mastoid
air cells near the ear canal can be seen in OE. (Fig. 2)
OE with cellulitis is treated by cleaning the ear canal and placement
of an expandable ear wick to allow penetration of ototopical drops with

⁎
Corresponding author.
E-mail address: glenn.isaacson@temple.edu (G. Isaacson).

https://doi.org/10.1016/j.visj.2020.100889
Received 5 September 2020; Accepted 17 September 2020
Available online 25 September 2020
2405-4690/ © 2020 Elsevier Inc. All rights reserved.

Downloaded for Fakultas Kedokteran Universitas Hasanuddin (tht_fkunhas@yahoo.com) at Hasanuddin University from ClinicalKey.com by
Elsevier on October 18, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
S. Beatty and G. Isaacson Visual Journal of Emergency Medicine 21 (2020) 100889

Fig. 3. Otoscopic view of otitis externa. There is ear canal edema. Purulent
discharge coats the ear canal and the surface of the tympanic membrane.

3. Questions
Fig. 1. Photograph of an outstanding left ear with postauricular cellulitis.
1) In the middle of July, a 9 year-old avid swimmer presents to your
office complaining of significant pain and otorrhea. On exam, there
is a protruding ear and tenderness on movement of the pinna. On
otoscopy you would expect to see:
a) A bulging, immobile tympanic membrane
b) Diffuse edema and exudate in the external auditory canal
c) Tympanic membrane perforation
d) A foreign body in external auditory canal
2) A 3 year-old child presents to the ED with significant ear pain, an
outstanding pinna with postauricular erythema and fluctuance.
Otoscopy shows a red, bulging tympanic membrane. Computed to-
mography of the temporal bone would most likely show:
a) Diffuse thickening of the external ear canal
b) Air in the middle ear and mastoid
c) Bony narrowing of the osseous EAC
d) Mastoid opacification with loss of mastoid trabeculae

4. Answers to questions

1) B – The patient presentation, age, seasonality, and exam findings

point toward otitis externa, which would have an edematous canal
with exudate.
2) D – This CT description matches with acute mastoiditis as do the
patient's presentation and demographics.

Fig. 2. Axial computed tomogram of the temporal bone. There is soft tissue Funding
density filling the external auditory canal with minimal middle ear inflamma-
tion. None.

Declaration of Competing Interest

activity against Pseudomonas and Staphylococci (ciprofloxacin, oflox-
acin, neomycin polymyxin B). Addition of an oral antibiotic with ac-
tivity against Staphylococcus aureus and Streptococci (amoxicillin- None.
clavulanate or a cephalosporin) is sufficient to treat the secondary
cellulitis. AOM with coalescent mastoiditis usually requires hospital References
admission for intravenous antibiotics, tympanostomy tube placement
and sometimes surgical mastoidectomy. 1. Hopkin RJ, Bergeson PS, Pinckard RC, Lewis K. Otitis externa posing as mastoiditis.
Arch Pediatr Adolesc Med. 1994;148(12):1346–1349. https://doi.org/10.1001/
archpedi.1994.02170120108022.

Downloaded for Fakultas Kedokteran Universitas Hasanuddin (tht_fkunhas@yahoo.com) at Hasanuddin University from ClinicalKey.com by
Elsevier on October 18, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
S. Beatty and G. Isaacson Visual Journal of Emergency Medicine 21 (2020) 100889

2. Stähelin-Massik J, Podvinec M, Jakscha J, et al. Mastoiditis in children: a prospective, 3. Trojanowska A, Drop A, Trojanowski P, Rosińska-Bogusiewicz K, Klatka J, Bobek-
observational study comparing clinical presentation, microbiology, computed tomo- Billewicz B. External and middle ear diseases: radiological diagnosis based on clinical
graphy, surgical findings and histology. Eur J Pediatr. 2008;167:541–548 https://doi- signs and symptoms. Insights Imaging. 2012;3(1):33–48. https://doi.org/10.1007/
org.libproxy.temple.edu/10.1007/s00431-007-0549-1. s13244-011-0126-z.

Downloaded for Fakultas Kedokteran Universitas Hasanuddin (tht_fkunhas@yahoo.com) at Hasanuddin University from ClinicalKey.com by
Elsevier on October 18, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.