The Daily Differential — Wednesday, May 27, 2026

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Mastoiditis

Mastoiditis is a complication of acute otitis media that can rapidly extend beyond the mastoid air cells to cause abscess, facial nerve palsy, venous sinus...

At the Bedside

Clinical clues
Fever, otalgia, otorrhea, postauricular erythema/swelling, tenderness over mastoid, and auricular protrusion are classic.
Often follows untreated or partially treated AOM.
Red flags: toxic appearance, headache, vomiting, neurologic deficits, diplopia, facial weakness, vertigo, altered mental status.
Exam
Inspect for ear displacement, fluctuance, overlying erythema.
Otoscopy may show AOM or perforated TM with otorrhea.
Full cranial nerve exam; assess gait, meningismus, and signs of intracranial spread.
Workup
CT temporal bone with contrast is commonly used to assess mastoid opacification, bony erosion, subperiosteal abscess, and extension.
CBC, CMP, blood cultures if febrile/toxic; ESR/CRP can help trend.
If neurologic signs or intracranial concern: broaden to CT/MRI brain and urgent specialty consultation.
Management
Start IV antibiotics covering common otic pathogens. Choice depends on age, severity, local resistance, and risk factors.
ENT consult early; drainage/myringotomy or mastoidectomy may be needed if abscess, coalescent mastoiditis, or failure to improve.
Analgesia, IV fluids if needed, and fever control.
Disposition
Admit almost all patients with true mastoiditis.
Outpatient management is generally not appropriate when true mastoiditis is suspected.
Complication awareness
Intracranial extension, lateral sinus thrombosis, facial nerve palsy, and hearing loss are the big misses.
Mastoid tenderness alone can occur with uncomplicated otitis; the diagnosis is strengthened by swelling, ear protrusion, systemic illness, and imaging findings.

A Classic Presentation

A 7-year-old boy with 5 days of fever and worsening left ear pain after a recent ear infection now has swelling behind the ear and the pinna is pushed outward. Exam shows postauricular erythema, mastoid tenderness, and a purulent middle-ear effusion. CT temporal bone demonstrates mastoid air cell opacification with bony septal erosion. He is admitted, started on IV antibiotics, and ENT performs myringotomy with drainage.

Patient Presentation to Attending

This is a 7-year-old boy with recent otitis media who’s had worsening fever and left ear pain over the last 5 days. My main concern is mastoiditis because he now has postauricular swelling, mastoid tenderness, and auricular protrusion, which goes beyond uncomplicated AOM. On exam the mastoid is erythematous and tender, and otoscopy shows a purulent effusion; he does not have focal neurologic deficits or meningismus right now. I’m worried about coalescent mastoiditis or subperiosteal abscess, so I’d like CT temporal bone and ENT involved early. He needs admission for IV antibiotics, and if imaging or exam suggests abscess or he worsens, he may need drainage.

Study Directive

Memorize the clinical triad: postauricular swelling, mastoid tenderness, pinna protrusion.
Compare mastoiditis vs otitis externa vs uncomplicated AOM on one page.
Practice deciding when CT temporal bone is needed versus when bedside exam is enough.
Review the complications of mastoiditis and how they change imaging/admission decisions.
Build a simple admission checklist: IV antibiotics, ENT, neuro exam, cultures, imaging.

Key Medications

Ceftriaxone 1–2 g IV q24h
Vancomycin 15–20 mg/kg IV q8–12h, titrate to levels per institutional protocol
If severe beta-lactam allergy or specific concerns, regimen varies widely; check ENT/ID guidance and local antibiogram
Analgesia
- Acetaminophen 650–1000 mg PO/IV q6–8h PRN
- Ibuprofen 400–800 mg PO q6–8h PRN if appropriate
Pediatric note: Common pediatric regimens differ and are typically weight-based; verify local pathway. Pediatric mastoiditis often uses ceftriaxone ± vancomycin depending on severity/MRSA risk.

High-Yield Pearls

Auricular protrusion is a big red flag for mastoiditis/subperiosteal abscess.
Mastoiditis is usually a complication of AOM, not isolated ear canal disease.
Any cranial nerve deficit, severe headache, vomiting, or altered mental status raises concern for intracranial spread.

Board Question

A child with fever, otorrhea, and postauricular swelling has the pinna displaced outward. What is the best next step?

AOral antibiotics and outpatient follow-up
BCT temporal bone, ENT consult, and IV antibiotics
CReassurance that this is normal after ear infection
DTopical otic drops only

Reveal answer

Correct: B

Postauricular swelling with auricular protrusion is classic for mastoiditis and raises concern for bony involvement or abscess. This requires urgent imaging, ENT evaluation, and IV antibiotics, not outpatient treatment.

Recent Literature

Review or guideline Acute mastoiditis in children
Acta Biomed, 2020 · cited 77×

Full text · open access
Recent clinical Outcomes of tympanostomy tube insertion in the emergency department versus the operating room for acute mastoiditis in children
Am J Emerg Med, 2026

3 of 4

Nasal Trauma

Nasal trauma is common, but the ED must identify septal hematoma, CSF leak, septal deviation/obstruction, and associated facial fractures. Missing a septal...

At the Bedside

Initial priorities
Follow trauma principles first if high-energy mechanism: airway, breathing, circulation, C-spine as indicated.
Control epistaxis with pressure; assess for other facial injuries, ocular injury, malocclusion, and neurologic symptoms.
Focused nasal exam
Inspect for deformity, lacerations, edema, crepitus, and active bleeding.
Use nasal speculum/an otoscope with care if needed.
Look for septal hematoma: boggy, fluctuant swelling of the septum, usually bilateral obstruction; this is an urgent diagnosis.
Check for clear rhinorrhea, salty taste, or positional drainage suggesting CSF leak.
When to image
Isolated uncomplicated nasal fracture is usually a clinical diagnosis; x-rays rarely help.
CT maxillofacial/head if concern for other facial fractures, high-energy trauma, orbital injury, CSF leak, septal abscess, NOE/frontal sinus injury, or significant mechanism.
Management
Septal hematoma/abscess: urgent drainage + antibiotics + ENT involvement; do not discharge.
Uncomplicated fracture: analgesia, ice, head elevation, discharge with ENT/plastics follow-up in 3–7 days when swelling improves for reduction if needed.
Epistaxis: direct pressure, topical vasoconstrictor, cautery if visible source, packing if persistent.
Disposition
Immediate ENT: septal hematoma, persistent deformity with obstruction, uncontrolled epistaxis, suspected open fracture or complex facial fracture.
Discharge: minor isolated fracture, no septal hematoma, no CSF leak, stable bleeding.
Common misses
Septal hematoma in children is easy to overlook.
A “broken nose” with clear nasal drainage after head trauma may be a skull base fracture until proven otherwise.

A Classic Presentation

A 19-year-old man is punched in the nose during a bar fight and presents with epistaxis and nasal pain. Bleeding stops with pressure, but he reports progressive bilateral nasal obstruction. Exam shows a swollen, tender, deviated nose and a soft fluctuant septal swelling. CT is not needed to diagnose the septal hematoma. ENT is called immediately for drainage to prevent cartilage necrosis.

Patient Presentation to Attending

This is a 19-year-old man with blunt nasal trauma after an assault about 2 hours ago. My main concern is a septal hematoma because he has persistent obstruction and a fluctuant septal swelling, which is the complication we can’t miss. He had epistaxis initially but it’s controlled now, and he doesn’t have vision changes, malocclusion, or other concerning facial injuries on exam. I’m less worried about an isolated nasal fracture needing emergent imaging because this looks like a clinical diagnosis, but I’d still consider CT if we find other facial trauma or a CSF leak. ENT needs to evaluate him now for drainage, and if that’s excluded he can follow up for delayed reduction.

Study Directive

Practice a 60-second nasal trauma exam: deformity, septum, bleeding, obstruction, CSF leak, facial/orbital exam.
Make a “when to image” list for facial trauma.
Memorize the hallmark of septal hematoma: boggy fluctuant septal swelling + obstruction.
Review delayed reduction timing for uncomplicated nasal fractures.
Write out a trauma checklist for associated injuries: ocular, dentition, mandible, brain.

Key Medications

Topical oxymetazoline 0.05%: 2–3 sprays per nostril; may repeat once after several minutes for epistaxis
Topical lidocaine + epinephrine or local anesthetic for reduction/laceration repair per procedural needs
Analgesia
- Acetaminophen 650–1000 mg PO q6–8h PRN
- Ibuprofen 400–600 mg PO q6–8h PRN if no contraindication
If septal hematoma/abscess or packing with concern for infection:
- Antibiotic choice varies; common ED/ENT practice may include amoxicillin-clavulanate 875/125 mg PO BID or another agent depending on local flora and packing type — confirm with ENT/institutional protocol
Procedural sedation / anxiolysis if reduction needed: use standard ED agents per protocol; dose depends on age/comorbidity and is procedure-specific.

High-Yield Pearls

Septal hematoma = emergency drainage.
Routine x-rays do not help much with isolated nasal fracture management.
Clear rhinorrhea after facial trauma is a CSF leak until proven otherwise.

Board Question

A 13-year-old boy is brought in after being hit in the nose with a baseball. He has nasal obstruction and on exam has bilateral septal swelling that is soft and fluctuant. What is the most appropriate management?

ADischarge with ice and routine follow-up
BCT nasal bones and outpatient ENT referral in 1 week
CUrgent drainage of septal hematoma with ENT consultation
DIntranasal steroids and decongestants only

Reveal answer

Correct: C

A septal hematoma is a surgical emergency because it can lead to cartilage ischemia, necrosis, and deformity. It requires prompt drainage and ENT involvement; imaging is not needed to make the diagnosis.

Recent Literature

Review or guideline Evidence-Based Nutritional Interventions in Wound Care
Plast Reconstr Surg, 2021 · cited 50×
Recent clinical Trauma re-experiencing episodes during esketamine treatment in patients with treatment-resistant depression and comorbid PTSD: a retrospective case series
Eur J Psychotraumatol, 2026 · cited 1×

Full text · open access

4 of 4

Noninfectious Ear Emergencies

Not every painful or symptomatic ear is infected. ED clinicians need to recognize time-sensitive noninfectious conditions like sudden sensorineural hearing...

At the Bedside

Sudden hearing loss
Treat sudden sensorineural hearing loss (SSNHL) as an otologic emergency: sudden unilateral hearing loss over hours to 72 hours, often with tinnitus or fullness, normal ear canal/TM or minimal findings.
Perform bedside tuning fork tests if available:
Weber lateralizes to the good ear in SSNHL.
Rinne remains positive on affected side.
Urgent ENT/audiology; steroids are time-sensitive.
Rule out stroke/central cause if neuro deficits, vertigo, ataxia, diplopia, or other focal findings.
Auricular hematoma
Fluctuant swelling of the pinna after trauma.
Needs prompt drainage/pressure dressing to prevent cauliflower ear; ENT or a skilled ED clinician should manage.
TM perforation / barotrauma
Ear pain, hearing loss, tinnitus, sometimes vertigo after slap, blast, diving, or instrumentation.
Most small perforations heal spontaneously; keep ear dry, avoid ototoxic drops, arrange ENT follow-up.
Vertigo, facial weakness, or persistent severe hearing loss suggests more serious inner ear injury.
Foreign body
Common in children and intoxicated adults.
Remove only if clearly visible and safely retrievable; button batteries and paired magnets need emergent removal.
Cerumen impaction
Can cause hearing loss, fullness, pain, or dizziness.
Treat with irrigation if TM intact and no contraindication, or cerumenolytics/manual removal.
Referred/other causes
TMJ dysfunction, dental pain, herpes zoster oticus (vesicles, facial palsy), temporal arteritis in older adults with jaw claudication/vision symptoms, and tumor-related obstruction can mimic ear complaints.
Disposition
Urgent ENT: SSNHL, auricular hematoma, complicated TM perforation, foreign body that cannot be removed, button battery, facial nerve palsy, severe vertigo, or suspected perilymph fistula.
Discharge with precautions: uncomplicated cerumen impaction after treatment, small TM perforation, minor canal trauma.

A Classic Presentation

A 58-year-old man wakes up with sudden complete hearing loss in his left ear and tinnitus but no pain or fever. Exam shows a normal external canal and no obvious otitis. Tuning fork testing supports sensorineural loss, and he has no facial droop or focal neurologic deficit. He is started on high-dose steroids and gets urgent ENT follow-up for audiology and possible intratympanic therapy.

Patient Presentation to Attending

This is a 58-year-old man with sudden unilateral hearing loss that started when he woke up this morning. My main concern is sudden sensorineural hearing loss, because the ear exam is basically normal and the hearing change was abrupt over hours, which is time-sensitive. He has tinnitus but no ear pain, fever, or trauma, and he doesn’t have any focal neurologic deficits, vertigo, or gait instability to push me toward a central cause. Bedside tuning fork testing supports sensorineural loss on the affected side. I think he needs steroids now and urgent ENT/audiology follow-up, with a lower threshold for stroke workup if anything neurologic appears.

Study Directive

Practice tuning fork interpretation: Weber and Rinne in conductive vs sensorineural loss.
Build a “painful ear but not infected” differential card: SSNHL, hematoma, TM perforation, foreign body, zoster, TMJ.
Memorize when to avoid irrigation: TM perforation, foreign body concern, severe canal trauma, button battery.
Review steroid timing and ENT referral urgency for SSNHL.
Sketch the management steps for auricular hematoma drainage and pressure dressing.

Mechanism Pearl of the Day: Many “ear emergencies” are really anatomy problems: canal disease causes tragal pain, middle-ear disease causes bulging TM and conductive symptoms, and inner-ear/cochlear injury causes sudden hearing loss with a normal exam. The ED skill is matching the symptom pattern to the anatomic compartment quickly enough to catch the few cases that need urgent drainage, imaging, or steroids.

Key Medications

SSNHL steroids:
- Prednisone 1 mg/kg/day PO up to 60 mg daily, typically 7–14 days then taper per ENT protocol
- Alternative regimens vary; check ENT guidance
Pain control:
- Acetaminophen 650–1000 mg PO q6–8h PRN
- Ibuprofen 400–800 mg PO q6–8h PRN if appropriate
Cerumenolytics:
- Carbamide peroxide 6.5%: 5–10 drops BID for up to 4 days (product-specific instructions vary)
Button battery / magnet foreign body
- No medication; urgent procedural removal
TM perforation
- Avoid aminoglycoside ear drops; if contaminated injury or infection concern, antibiotic selection varies and should follow ENT/local guidance

High-Yield Pearls

Sudden hearing loss with a normal ear exam is SSNHL until proven otherwise.
A button battery in the ear is an emergency because it causes rapid tissue necrosis.
Auricular hematoma must be drained quickly to prevent cauliflower ear.

Board Question

A patient develops sudden unilateral hearing loss and tinnitus over several hours. Ear exam is normal. What is the best next step?

AOral amoxicillin
BHigh-dose corticosteroids and urgent ENT follow-up
CReassurance and routine follow-up in 2 weeks
DEar irrigation for cerumen impaction

Reveal answer

Correct: B

Sudden sensorineural hearing loss is an otologic emergency and should be treated promptly with corticosteroids while arranging urgent ENT follow-up. Delay reduces the chance of hearing recovery.

Recent Literature

Review or guideline MR imaging findings of endophthalmitis
Neuroradiol J, 2016 · cited 23×
Recent clinical Development of a Loop-Mediated Isothermal Amplification (LAMP) for the screening of Candida auris
PLoS One, 2026

Full text · open access

TheDaily Differential

Infectious Ear Emergencies

At the Bedside

Study Directive

Recent Literature

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