Auricular Protrusion: Not Only Mastoiditis
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PICTURE OF THE MONTH
Auricular Protrusion: Not Only Mastoiditis Kazuki Iio 1
&
Anna Otani 1 & Shun Kishibe 2 & Hiroshi Sakakibara 1
Received: 3 December 2019 / Accepted: 5 February 2020 # Dr. K C Chaudhuri Foundation 2020
A 3-y-old boy with a history of recurrent otitis media presented with left auricular swelling. This patient had a tendency of developing large erythematous swelling after insect stings. On the morning of the day of his presentation, his mother noticed swelling in his left auricle, which was not present the previous night. Although the patient did not report feeling any pain, he experienced pruritus around the swelling. Due to a lack of improvement, he was taken to authors’ hospital that night. He was in a good mood at the presentation and neurological examinations were normal. In addition to the erythematous swelling and protrusion of the left auricle, postauricular swelling was also observed (Fig. 1). No abnormal findings were noted on his tympanic membranes. To exclude the possibility of acute mastoiditis complicated with periosteal abscess, cranial computed tomography (CT) was performed. The CT revealed clear mastoid air cells and postauricular edema pressing anteriorly on the left auricle (Fig. 2). Although the authors first initiated antibiotic treatment because they suspected bacterial involvement, they finally diagnosed the patient’s condition as a reaction to an insect sting due to the lack of pain and acute onset of symptoms. The following day, they stopped the antibiotic treatment. The patient’s symptoms completely resolved at two days after this presentation. Since he had no history of systemic symptoms associated with insect
* Kazuki Iio [email protected] 1
Department of General Pediatrics, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
2
Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
stings by then, authors didn’t proceed to allergy test or venom immunotherapy. Insect stings may cause large local reactions in specific patient populations [1]. Less than 5% of them present with anaphylaxis to stings in the future, which require epinephrine injection and in-hospital monitoring [1]. The presentation of large local reactions may vary since it can appear anywhere on the skin. Due to resulting inflammation, these reactions mimic the symptoms of some bacterial infections or autoimmune diseases, which require prompt intervention. Cellulitis is one of the most common misdiagnoses of these large local reactions [1]. Several studies have reported children with large local reactions presenting with a red auricle, thus mimicking relapsing polychondritis [2, 3]. In the present patient, the swelling extended to the postauricular region and pressed on the auricle anteriorly, which misled authors to suspect acute mastoiditis. Due to the life-threatening complications of acute mastoiditis [4], ruling out acute mastoiditis is mandatory in the assessment of auricular protrusion. However, one should also be aware that auricular pr
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