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Care priority and warning signs
Care priority
Refer URGENTLY
Red flags
- Tender swelling behind the ear
- High fever
- Signs of systemic illness (lethargy, poor feeding)
- Facial nerve palsy
- Signs of meningitis (stiff neck, altered consciousness)
Assessment
- Ask: Does the child have an ear problem?
- Ask: Is there ear pain?
- Ask: Is there ear discharge? If yes, for how long?
- Look/Feel: Feel for tender swelling behind the ear.
Classification
- Tender swelling behind the ear -> MASTOIDITIS
Key features
- Presence of Tender Swelling Behind the Ear.
- Indicates spread of infection from the middle ear to the mastoid bone.
- Requires urgent hospital management to prevent serious complications.
Management
Non-pharmacological management
- Keep child comfortable.
- Quickly complete assessment for other pre-referral needs.
Pre-referral treatment
- Give first dose of an appropriate IM antibiotic (e.g., Ampicillin + Gentamicin or Ceftriaxone - see page 12 for doses).
- Give first dose of Paracetamol for pain/fever (10-15 mg/kg). Dose (500mg tablet): 2-3m (<6kg): 1/4 tab. 4m-3y (6-<14kg): 1/2 tab. 4-5y (14-19kg): 3/4 tab (or 1/2 of 500mg tab from p15).
- Treat for low blood sugar if needed (see page 12).
- Give other relevant pre-referral treatments if other severe classifications present.
Follow-up
- To be managed at referral hospital facility (typically requires IV antibiotics, possibly surgery).
Counselling points
- Explain that the swelling behind the ear is a serious infection requiring urgent hospital treatment.
- Explain treatments given (antibiotic, pain relief).
- Advise on keeping child comfortable during transport.
- Write a detailed referral note indicating mastoiditis and treatments given.
Differential diagnosis
- Postauricular lymphadenopathy (swollen lymph node, may be tender but usually more mobile)
- Acute Otitis Media (without mastoid involvement)
- Otitis Externa (infection of ear canal)
- Cellulitis over mastoid area
Complications
- Meningitis
- Brain abscess
- Facial nerve paralysis
- Hearing loss (conductive or sensorineural)
- Labyrinthitis
- Sepsis
- Venous sinus thrombosis
Prevention
- Prompt and appropriate treatment of Acute Otitis Media.
- Pneumococcal vaccination (PCV).
- Hib vaccination.
References
IMCI Chart Booklet - Page 5, Page 12 (Antibiotic), Page 15 (Paracetamol)