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Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky; President, Kentucky Pediatric and Adult Research Inc.; and General Pediatrician, Bardstown, Kentucky.
Disclosure: Dr. Block has no relevant financial relationships to disclose.
<bold>Practical advice for treating newborns and toddlers.</bold>
I have discussed the complexities of head and neck cellulitis in previous columns of <italic>Pediatric Annals</italic>.1â[euro]"3 However, over the past decade, other pediatricians and I who practice in areas with warm climates have been witnessing multiple cases of the great mastoiditis mimickerâ[euro]"retro-auricular acute cellulitis. Just like mastoiditis, this specific infection is a surprisingly complex diagnostic and management issue that you will certainly encounter at some time. As in other recent summers, in 2014, I have already treated five cases of peri-auricular cellulitis within our large, rural pediatric practice.
By contrast, as most private practice pediatricians have also recently observed, mastoiditis has become almost as uncommon as bacterial meningitis in our practices. I have seen only one case of each infection in the past decade. Most likely, this is a wonderful consequence of our highly effective vaccine programs leading to high infant uptake of both <italic>Haemophilus influenzae</italic> type B (HIB) vaccine and pneumococcal conjugate vaccines (PCV7/PCV13).
<bold>Retro-Auricular Redness and the Protuberant Ear</bold>
How should a pediatrician approach the patient with skin redness behind the ear and a protuberant pinna, as in <bold>Figures 1 and 2</bold>? Does your approach change when you cannot see the tympanic membrane due to either marked canal swelling or obstruction due to purulent matter? Or when the tympanic membrane is normal? Or even if it looks infected? Does pain on palpation of the tragus or pinna change your approach?
Most important, the causative bacterial pathogens differ significantly between the mastoiditis/peri-orbital cellulitis/facial cellulitis group and the peri-auricular cellulitis associated with external otitis, which includes both pre-auricular and retro-auricular cellulitis. The infectious agents in the former infections are typically <italic>Pneumococcus</italic>, Group A <italic>Streptococcus</italic>, and sometimes nontypeable <italic>Haemophilus influenzae</italic> and <italic>Staphylococcus aureus</italic>. These are the usual middle ear and skin pathogens.
However, in many mastoiditis series, the third leading cause of mastoiditis is <italic>Pseudomonas aeruginosa</italic>.4,5 But, is this bacterium actually a primary pathogen recovered from the middle ear or mastoid aspiration? Or has the bacterium instead been recovered from...