Tuesday, December 21, 2010

A 2 Year Old with an Unusual Ear Infection

I was working in a rural health clinic in Texas when a mother came in with her 2 year old daughter who was having a fever.  Her daughter was very cute, but I could tell that the child was not feeling well, with her holding her hand over her left ear.
“Hi, I’m Sharon, I’m a physician assistant, can you tell me what’s going on with your daughter?”
“Well, she’s not been feeling good for the last couple of days.  She started running a fever a few days ago and she hasn’t been eating very well.  And since yesterday, she’s not left my sight, she’s just been hanging onto my dress and not playing like she usually does.”
“Has her nose been running, or has she been coughing at all?”
“Yes, she’s been coughing for the last week or so and her nose has been running and congested for the past week.  I thought it was a cold at first, but now I don’t think so, seeing that she just keeps holding her left ear.”
“Okay, well let’s see what’s going on then.” 
With that, I looked again at the patient’s chart to check the daughter’s temperature.  The chart said she was running a temperature of 101.5 F.  Putting the chart down, I started doing my physical exam on the toddler.  I listened to her chest and heart sounds while she was sitting quietly in her mother’s lap.  They were normal. 
I took a quick look at her runny nose which was draining yellow fluid.  Her eyes were clear, she didn’t have any conjunctivitis.  Now I had to try a get a look at her throat.  This wasn’t going to be easy. 
Her mom saw what I was attempting to do when I came near her daughter with a tongue blade in my hand. 
“I’m going to have to lay her down on the exam table, she’s not going to open her mouth otherwise.”
Her mother started to stand up, and with that her daughter started to cry and let out loud wails.  The toddler fought being laid down on the exam table.  Her mom and I had to both help hold her on the exam table.  Once the daughter figured out what we were going to do she locked her jaw shut.   So, I had to slowly pry her mouth open using the tongue blade. 
I finally was able to get a quick look at her throat which was slightly red.  Now I had to get a look at her ears.  I picked up the otoscope and looked into her right ear first.  Her tymphanic membrane was red, she had dark serous drainage behind the membrane. 
Now to the left ear.  Her mom and I both rolled the toddler’s head to the right and as I did this, I felt a definite softness behind the left ear. 
Palpating further it was no mistake the daughter had mastoiditis.  The mastoid bone which is positioned immediately behind the ear auricle was soft and mushy.  This set off an alarm within me.  Her mom held her hands down, while I used the otoscope to look in the toddler’s left ear.  Her tymphanic membrane was ruptured, there was green drainage coming from her ear canal.  Then there was the smell, I recognized it, my memory quickly brought me back to where I remembered it from. 
I had seen a patient in Houston while I worked for an infectious diseases practice who had an infected sternum from his open heart surgery procedure.  His chest wound was draining green fluid from it and it ended up being pseudomonas aeruginosa.  It was a nasty bacteria to have to deal with.  
With that memory in mind, I knew I had to get the toddler into seeing a pediatric ear, nose and throat specialist (ENT) and quickly.  This was one sick child.  I excused myself from the exam room. 
I picked up the clinic phone and called directory assistance for Houston.  I asked for the number to Texas Children’s Hospital and once I had their main number, I called it and immediately asked to be switched over to the ENT clinic.  The receptionist at the front desk picked up the phone.
“Hi, I’m Sharon and I’m a physician assistant and I need to make an appointment for a patient I’ve just seen who needs to be seen urgently by one of the ENT attendings.  She has mastoiditis caused by pseudomonas.”
“Well, there isn’t an opening for a new patient until 3 days from now, will that do?”
“No, this patient needs to be seen within 24 hours.”
“Well then let me switch you back to one of the clinic nurses, and let’s see what they can do for you.”
When the clinic nurse picked up the phone, I explained to her what was going on with my patient in the rural health clinic which was an hour’s drive north of Houston. 
“Whoa, that’s a nasty infection.  Hang on the phone, let me go talk to one of the ENT attendings, and I’ll be back on the line in a minute or two.”
“Sure, no problem.”
“I talked to Dr. Davids, and he said to tell the mom to get her daughter down here right away, he’ll see her at 3 pm.  Can she do that?”
“Let me go check.  I’ll be right back.”
I knocked on the exam room door, opened it and quickly asked the toddler’s mom whether she could drive south to Houston and take her daughter to Texas Children’s Hospital to be seen by 3 pm.  I quickly advised her that her daughter had a very nasty infection and I needed her daughter to be seen by an ear, nose and throat specialist. 
“Yes, I can get her down there in time, tell them I’ll be there.”
“Wonderful, I’ll let them know.”
I picked up the clinic phone receiver and told the nurse at Texas Children’s Hospital that the mom would be there at 3 pm with her daughter.  The nurse asked me for the daughter’s name, address and insurance information, which I quickly gave to her.  With that I told the nurse thank you very much and hung up.
 I walked back into the exam room and gave the mom the instructions on how to get to Texas Children’s Hospital and where the ENT clinic was located inside of it.  I advised her as to which ENT physician was going to see her daughter and why it was so important for her to keep the appointment. 
She understood and left the clinic to keep the appointment with Dr. Davids.

Otitis media (inner ear infections) is a common infection seen in children up to age 6 or so.  It is typically caused by Strep pneumoniae, Haemophilus influenza, Moraxella catarrhalis or from a virus (adenovirus, influenza, rhinovirus or respiratory syncytial virus).  A major complication from it is infection of the surrounding bone, the mastoid.   The mastoid is located immediately behind the ear and is filled with air cells.  It becomes infected as a continuous process from the middle ear to the mastoid process.  Generally, children under the age of 2 years who have a history of recurrent ear infections are the ones who are at risk for acute mastoiditis. 

The infectious agents that are involved in acute mastoiditis are somewhat different than those infectious agents which can cause inner ear infections.  Bacterial agents involved in acute mastoiditis include:  Streptococcus pneumonaie, Streptococcus pyogenes, Pseudomonias aeruginosa, and Staphylococcus aureus.

If a child has acute mastoiditis they need to be seen by a ear, nose and throat physician (ENT).  Having mastoiditis can involve many complications which includes spread of the infection to the lining of the brain.  Due to the potential severity of acute mastoiditis this has to be treated with intravenous antibiotics   The ENT physician will follow the child to make sure that they have not lost hearing in the affected ear and that there is total clearance of the infection.
The following day in clinic the mother was back with her two year old toddler in tow.  She beckoned me over to where she was. 
“Dr. Davids was glad that you had sent my daughter down to see him.  You were right, she does have a very nasty infection.  Dr. Davids took cultures of the drainage and put my daughter on daily injections of Rocephin.  He gave her the first injection in the ENT clinic yesterday and sent these orders with me to give to you today.”
“Okay, let me have a look at them.”
I quickly scanned the physician orders he had written for the two year old.  Dr. Davids wanted the toddler to receive a daily intramuscular injection of Rocephin for the next two weeks and then she was to go back and see him in clinic. 
“Let me get a hold of the visiting nurse association, they’ll have to come out to your house every day and give your daughter the injections of antibiotics.  So take a seat while I contact them.”
“Okay, thanks.”
I picked up the phone and called the local VNA and advised them of the physician orders.  After hanging up the phone, I faxed the orders over to them.  Thirty minutes later they called me back and told me that they had acquired insurance clearance for the next two weeks and they would be out to do the first injection that afternoon.
“Great, I’ll let the mom know to expect you.”

Using Rocephin for a Pseudomonas infection was a very good choice.  The child could receive the antibiotics once a day at home and yet it would last for 24 hours.  The child would also not need to have an intravenous line placed by doing the injections intramuscularly every day.  The child could also stay at home and not be hospitalized.  And as long as the child received appropriate follow-up on their infection, this was a safe alternative to a prolonged hospitalization.

I walked out into the clinic’s waiting area and told the mom who to expect at her home and how to contact the VNA if she had any problems.  With that she left to go home. 
I didn’t expect to have any more follow-up on the toddler, but I was wrong.  Ten days later the mom and her well looking toddler were back in the clinic again.
“I went into the exam room and found the mom with her daughter sitting there waiting for me. 
“What’s going on?,” I asked.
“I can’t deal with it anymore!  Every time the VNA nurse comes out to the house, my daughter takes off running to hide in the nearest closet and then when I end up having to pull her out of the closet she just starts wailing and screaming at the top of her lungs. 
I can’t deal with these injections anymore.”
“Okay, well let me take a look at her and then I’ll see what I can do.”
I did a quick physical assessment of her and found that her fevers were gone, the green drainage from her left ear was gone, the mastoid process was not as soft as it had been and her right ear was normal.  She even had a tymphanic membrane once more on the left side. 
I excused myself to call the ENT clinic at Texas Children’s Hospital again.  Fortunately when I switched over to the clinic and then into the nurse’s station I was given the same nurse who helped me before. 
“Hi, this is Sharon again, the PA who works in the rural health clinic north of Houston.  I sent a patient down there to be seen by Dr. Davids about 10 days ago and he saw her as an emergency.  She’s the one who had mastoiditis caused by pseudomonas.  Do you remember?”
“Yes, I do.  How can I help?”
“Well, I have the mom and her daughter back in my clinic right now.  The mom brought her in due to her daughter having screaming attacks every time the VNA shows up to give her another Rocephin injection.  I was wondering whether you could find Dr. Davids for me and ask him whether there was possibly some oral antibiotic that the patient could be switched over to instead.  The daughter is due to see him on Thursday, 3 days from now.  I took a quick look at her and everything seems to be healing up nicely, thank goodness.”
“Great, let me go corner him, he’s just finishing up with another patient.”
Shortly thereafter Dr. Davids came on the line.   “Hi, this is Dr. Davids.  The nurse has informed me that you have my patient back in the clinic.  I’ve been told that she’s a lot better, but fears her injections.”
“That sums it up.  Is there anything else we can switch her over to?  What did the culture and sensitivity microbiology report show regarding her Pseudomonas?”
“Well, the Rocephin she’s on is the easiest one for her right now.  It only has to be given once a day as opposed to putting in a central line and giving her intravenous antibiotics twice a day or three times a day.  Can you try to talk to her mom and advise her that she only needs 3 more injections and then I’ll stop the meds and she’ll be done.”
“And if I can’t do that, what shall I do?”
“Well I don’t want her to have to stop her meds before I would know for sure that her mastoiditis is treated, but if her mom is insistent the Rocephin not be continued for 3 more days, then go ahead and discontinue it and make sure that she keeps her appointment with me in 3 days.”
“Okay, thanks for your help.”
I went back into the clinic exam room and advised the little girl’s mom of what Dr. Davids has just said.  The patient’s mom was in tears as she explained to me how her daughter was terrified of the VNA nurse when she showed up.  I knew the mom was not going to be able to make it through to Thursday which would finish out her 14 days therapy.  Her daughter had already received 10 days of IM Rocephin and that would have to do.  I told the mom that Dr. Davids had given me permission to discontinue the IM injections.
“Thank you, thank you.  You don’t know how much I appreciate that, I’ll finally have my daughter back again.”
“Dr. Davids wants to make sure that you keep the appointment for your daughter on Thursday down at Texas Children’s.”
“I’ll make sure she keeps it.”
“Okay, I’ll call the VNA and let them know to discontinue their daily visits out to your house.”  
“Thanks again.”  With that the mom and her daughter left the clinic. 
A week later I received a follow-up letter from Dr. Davids advising me that he had seen our mutual patient and had determined that her mastoiditis was cleared up and he had discharged her from any further follow-up.    
This child has dodged the bullet regarding having any complications from her acute mastoiditis.  Thankfully she had a positive outcome.  Positive outcomes with patients are dependent upon many different factors.  One is that they have to be involved in the process, they need to feel as though they are a part of the process of getting well and that they need to be involved for the positive outcome to come about.  Another aspect which affects the outcome is whether the patient takes responsibility for their own health care, are they willing to make the necessary changes in their life, are they willing to be accountable, return for their clinic appointments, etc.  And a third aspect of whether the patient has a positive outcome or not involves the patient’s feelings towards their medical care provider.  Do they believe you care about whether they get well or not?  Most patients want to cooperate, but they also need to know that you, the provider will be there as their coach, cheering on their success’.   


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