Acute mastoiditis with temporomandibular joint effusion.

otitis media has a markedly lower incidence of intra-and extratemporal sequelae today than in the pre-antibiotic era. Among the complications of acute otitis media, mastoiditis continues to be the most common intratemporal complication. The classic description of acute mastoiditis involves a child with antecedent acute otitis media who develops high fever, severe otalgia, postauricular erythema, and tenderness. There is frequently a degree of postauricular swelling, suggesting the presence of subperiostial abscess. Contemporary studies of mastoiditis describe the clinical presentation with several prominent clinical features, including otalgia (98% incidence), fever (83%), abnormal appearance of the tympanic membrane (88%), abnormal appearance of the external auditory canal (80%), postauricular edema (76%), auricular proptosis (42%), and otorrhea (26%). 1 Because the overall incidence of mastoiditis has plummeted in the postantibiotic era, it is less frequently encountered by the otolaryngologist. Atypical presentations , therefore, have become proportionately more scarce and present a diagnostic challenge to the clinician. We describe a case of acute, coalescent mastoiditis whose atypical presentation, with massive TMJ effusion and trismus, highlights the anatomic relationship of this joint to the mastoid and middle ear. An 11-year-old female with no otologic history and no significant medical history presented to the emergency department with a 4-day history of left-sided otalgia. She had arrived from Eastern Europe 4 weeks earlier and shortly after arrival developed bilateral otalgia and a low-grade fever. She was diagnosed with bilateral acute otitis media and given a 10-day course of antibiotics orally with complete resolution of her symptoms. Four days before presentation, she developed left-sided otalgia and was again diagnosed with acute left otitis media and treated with amoxicillin. She presented to our emergency department with increased left-sided otalgia. History revealed daily ocean swimming. Her physical examination was significant for marked tragal tenderness and fullness, and an edematous external auditory canal (EAC). A small posterosu-perior crescent of her tympanic membrane was visible; however , mobility could not be adequately assessed because of significant canal edema. Her mastoid tip was nontender and nonerythematous, and the auricle was nonproptotic. She had normal hearing bilaterally, and no vestibular symptoms. The remainder of her otolaryngologic examination was normal. She was diagnosed with otitis externa and given cortisporin otic suspension and placed on water precautions. Because her middle ear was not able to be thoroughly assessed, the presence of infection was presumed, and she was continued on oral antibiotics. Thirty-six hours later, she returned with …