Otalgia, Fever and Facial Nerve Palsy

A 50yM non-diabetic with a history of HTN presented to the ED with 4 days of right-sided otalgia and fever. Onset of pain occurred after cleaning his ear with a cotton-tipped swab (“Q-Tip”) after a shower. The following day his pain worsened and he developed a low-grade fever. He saw his primary care physician and was diagnosed with a perforated tympanic membrane and acute otitis media (AOM). He was placed on amoxicillin and eardrop steroid solution.

Two days later, he presented to the ED with worsening swelling of his right ear/face, persistent fevers and a new facial nerve palsy that he noticed when he woke up in the morning.

On exam, the patient was febrile at 38.5 degrees with otherwise normal vital signs. He had an obvious right facial droop and was unable to completely close his right eye or raise his right eyebrow (consistent with a lower motor neuron lesion). There was soft tissue swelling anterior to his right ear. His TM was difficult to visualize due to canal swelling and purulent discharge. He was tender along the mastoid.

He was started on IV ceftriaxone for presumed diagnosis of acute mastoiditis while CT of the head/mastoid was being arranged.

CT results are below.

CT head showing significant soft tissue swelling anterior to the right ear

CT mastoid demonstrating air-fluid levels of the right mastoid.

He was admitted for IV antibiotics and responded well, negating the need for surgery. He facial nerve palsy resolved over the next 4 days.

The course of the facial nerve is nicely depicted on this website from Yale School of Medicine http://info.med.yale.edu/caim/cnerves/cn7/cn7_20.html. Paresis can occur as a result of compression due to localized swelling or due to direct spread of infection. In this case, I am not sure where anatomically it occurred, as he had AOM, mastoid involvement, and substantial swelling anterior to the ear, which may have also compressed the nerve.

 Learning Point:

• Facial nerve palsy can complicate AOM, suppurative chronic otitis media and mastoiditis.
• Aggressive management of the underlying condition is prudent to avoid long-standing neurologic deficit.