Case Presentation: A 6-year-old male with 4-month history of recurrent otitis media presented with one day of headache, ear pain, and left-sided facial droop. Parents claimed that he completed multiple courses of different antibiotics and steroids with incomplete resolution of symptoms. On presentation, he was afebrile. Physical exam was notable for left facial paresis House-Brackmann grade V with asymmetry at rest. Neurologic exam showed a compromised cranial nerve VII. Otoscopic exam showed an intact, dull left tympanic membrane with purulent effusion and erythema. No proptosis of the auricles, postauricular erythema, or vesicles surrounding the left ear. Hearing test revealed no hearing loss. The rest of the physical exam was unremarkable. Lab results showed normal CBC and BMP, with a slightly elevated CRP. CT scan demonstrated left otomastoiditis without coalescence or abscess formation, consistent with mastoiditis. Patient underwent surgical decompression with bilateral myringotomy and ventilation tube placement, as well as adenoidectomy. He was started on IV ceftriaxone combined with steroids. Postoperative day 1, he exhibited worsening left asymmetry consistent with House-Brackmann VII. MRI was obtained, which ruled out intracranial extension. Patient was ultimately diagnosed with left facial palsy secondary to recurrent otitis media complicated by silent otomastoiditis. Patient was discharged home on oral levofloxacin to complete 28 days. Two weeks after discharge, on a follow-up appointment with infectious disease, he demonstrated improvement in his left facial palsy, with complete resolution after 1 month.
Discussion: Facial nerve palsy is an uncommon complication, with an incidence of 0.005% (1). There are very few cases reported in pediatric literature (2) (3) (4). Though otitis media (OM) is one of the most common diseases seen in infants and children; early diagnosis and the use of antibiotics have decreased the rate of complication. Some of this can be fatal without the appropriate treatment. Treatment of facial nerve palsy secondary to otitis media should be conservative with antibiotics and corticosteroids. Adjunctive myringotomy and a ventilation tube placement are recommended when there is no tympanic membrane rupture. Should there be no significant improvement after three weeks, mastoidectomy can be considered. In terms of prognosis, there is a 6% incidence of residual dysfunction, and the full recovery of facial palsy occurs within 3 months in 97% (2).
Conclusions: This case report highlights one of the rarer complications of otitis media. As noted in our patient, silent mastoiditis occurs by transient relief of clinical mastoid symptomology secondary to antibiotic treatment, while middle ear inflammation persists silently (5). Careful consideration should be taken in cases of persistent otitis media presumed to be unresponsive to outpatient antibiotic therapy and new-onset neurologic symptoms. These findings should evoke further evaluation for extracerebral findings, like mastoiditis, or intracranial findings, such as abscess or meningitis.