Aligned with the Pediatric Nursing Certification Board format. Authored & peer-reviewed by CPNPs.
Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.
A 5-year-old boy presents to his primary care provider accompanied by his mother, who is concerned by right ear pain and swelling behind his right ear. His mother also notes he has had intermittent fevers the past 4 days, which she has been treating with ibuprofen. He has had no antibiotic use within the last 6 months. On physical exam, the patient is lethargic, and there is significant postauricular erythema, swelling, and tenderness. His right tympanic membrane is bulging and erythematous. Which of the following therapies is most appropriate for this patient?
This patient has acute mastoiditis, which is an infection of the mastoid air cells of the temporal bone. This is the most common complication of acute otitis media if left untreated. The most common bacterial pathogens associated with mastoiditis are Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. The patient will present with postauricular tenderness, erythema, swelling, fever, and malaise. On physical exam, most patients will present with signs of acute otitis media, such as bulging and erythematous tympanic membrane, along with narrowing of the external ear canal and postauricular erythema, swelling, and tenderness. Imaging is not necessary to make the diagnosis of mastoiditis if the patient presents with characteristic clinical findings. However, if the diagnosis is unclear, then a CT with contrast scan of the temporal bone can be done to confirm the diagnosis. The CT scan would be significant for fluid in the mastoid air cells and irregularity of the mastoid cortex. Uncomplicated mastoiditis should be treated with intravenous antimicrobial therapy along with middle ear drainage. The antimicrobial therapy will depend on the patient’s previous medical history. If there is no recent antibiotic use and no history of recurrent otitis media, then vancomycin alone is the proper treatment. However, if the patient has had recent antibiotic use or if the patient has had recurrent otitis media, then vancomycin plus a cephalosporin, such as ceftazidime or cefepime, is the treatment of choice. Some complications of acute mastoiditis include meningitis, epidural or subdural abscess, facial nerve palsy, labrynthitis, hearing loss, osteomyelitis, and venous sinus thrombosis. If complications are present, then it is considered a complicated disease. In this case, treatment would include aggressive surgical management with a mastoidectomy plus intravenous antimicrobial therapy and myringotomy.
Mastoidectomy and intravenous antimicrobial therapy (B) along with a myringotomy is the proper treatment for complicated mastoiditis. The patient in this vignette presents with an uncomplicated case of mastoiditis. Myringotomy alone (C) is insufficient treatment for an acute episode of mastoiditis. It is important to also treat with intravenous antimicrobial therapy to resolve the bacterial infection. Oral antimicrobial therapy alone (D) will not sufficiently treat a case of mastoiditis.
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