A 14-year-old, previously healthy, fully immunized girl is presented to the emergency department (ED) with a 2-week history of left ear pain and discharge. She has just completed a 10-day course of antibiotic therapy, prescribed by her primary care provider, for marked left ear pain and swelling with purulent bloody discharge, headache, and left temporal and facial pain. She denies any history of foreign body in the ears, hearing loss, or fever. The review of systems is not contributory. Her past medical history is unremarkable, and the patient has no known history of allergy.
On examination, the patient is a young white girl who is ill-appearing but in no obvious distress. Her vital signs include a temperature of 97.9°F (36.6°C), a regular heart rate of 86 bpm, a respiratory rate of 16 breaths/min, and a blood pressure of 110/80 mm Hg. On examination of the head, swelling and tenderness are noted behind the left ear lobe, with purulent bloody discharge from the left ear. The central nervous system (CNS) examination reveals an alert and well-oriented young girl with a Glasgow Coma Score of 15/15. She is unable to wrinkle the left side of her forehead, she can not close her left eyelid, and the left nasolabial fold is flat and with deviation of the mouth to the right. The cardiovascular, respiratory, and abdominal examinations are all normal.
The initial laboratory analysis, which includes a complete blood cell count (CBC) and basic metabolic panel, are normal. Computed tomography (CT) scanning of the brain confirms a left-sided mastoiditis, but no findings to suggest increased intracranial pressure are noted. An analysis of the cerebrospinal fluid (CSF) shows no significant white or red blood cells or abnormalities in the glucose and protein concentrations. A swab of the purulent discharge from the left ear, blood, and CSF samples are sent for culture. She is admitted for suppurative otitis media, mastoiditis, and seventh nerve palsy. Infectious disease, head and neck surgery, and neurology specialists are consulted. Her initial management includes intravenous fluid, pain medications, tympanostomy for drainage and culture, and intravenous meropenem pending the culture and sensitivity results. On admission day 2, however, the patient develops severe left orbital pain, double vision, and the inability to abduct the left eye. The neurologist clinically confirms a sixth nerve palsy, and a request is made for magnetic resonance imaging (MRI) of the temporal bones, as well as magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) to rule out venous sinus thrombosis.