Physical Therapy Management Of A Patient With Unilateral Headache, Neck, And Shoulder Pain Who Presents With Undiagnosed Mastoiditis: A Case Report Alexandr Kostenko BS, SPT,1 1Doctor of Physical Therapy Program, University of New England, Portland, Maine

Mastoiditis Background Symptoms/Referral Patterns Outcomes o Due to the short duration of the patient’s episode of o Mastoiditis is an infection and inflammation of the Mastoiditis: Cervicogenic Headache: Common Sites of Cervicogenic Headache Referral mastoid cells.1 Mastoidectomy: care, there were no formal reassessments performed o If left untreated, mastoiditis can lead to and thus no follow-up outcomes. intracranial complications and ultimately death.1 o Diagnosis is confirmed with imaging such at Diagnostic Imaging Findings (MRI): computed tomography or magnetic resonance imaging.2

o Common symptoms include earache, https://cdn.websites.hibu.com/ca9a9cf4f5024372bc9c30f729fa5363/dms3rep/multi/tablet/cervicogenic-headache-areas-in-skull.png retroauricular pain, headache, mastoid tenderness, hearing loss, and discharge from the 2 ear. https://cdn-prod.medicalnewstoday.com/content/images/hero/322/322129/322129_1100.jpg https://assets.aboutkidshealth.ca/akhassets/Mastoidectomy_MED_ILL_EN.jpg?RenditionID=10 o Mastoiditis is typically managed with antibiotics, but may require mastoidectomy which is the surgical removal of the mastoid bone.3

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Discussion/Conclusions http://www.emdocs.net/wp-content/uploads/2016/03/Mastoiditis-1.jpg https://2minutemedicine-wpengine.netdna-ssl.com/wp-content/uploads/2014/11/Chronic-Otitis-Media-Cholesteatoma- and-Mastoiditis2.jpg o Treatment only improved patient’s symptoms in the Case Description and Purpose short term, as indicated by gradual increases in symptoms over time possibly due to worsening o Patient was 76-year-old Caucasian male referred to outpatient physical therapy from his otorhinolaryngologist (ENT) status of the mastoid infection. due to complaints of left-sided headache, neck, and shoulder pain which began three years ago. o One special test, “cervical flexion rotation rest4,” o Relevant medical history included chronic bilateral ear infections over the last ten years. which is specifically tailored for identifying if o Patient reported being limited in his ability to sleep, get dressed, bathe, as well as pick up and carry objects due to headaches are coming from the upper cervical increase in pain. segments was not performed. The test would likely o Assessment revealed deficits in active and passive left shoulder range of motion, left upper-extremity strength, have been positive due to painful neck movement cervical range of motion, and hypomobility of upper cervical vertebrae. Patient demonstrated tenderness to https://www.theadvancedspinecenter.com/wp-content/uploads/2018/08/understanding-cervicogenic-headaches-cover-photo.png and limited cervical rotation. palpation surrounding his left scalenes, sub-occipital musculature, upper trapezius, and paraspinals. o This case report may have potential implications for o The purpose of this case report is to illuminate the signs/symptoms of Mastoiditis as well as Cervicogenic Headaches clinical practice because there is a lack of education and their commonalities which include overlapping site of cervicalgia Cervicogenic Headache Background regarding mastoiditis in physical therapy o Cervicogenic headache (CGH) is typically a chronic, Timeline Interventions curriculums. unilateral cephalgia that is believed to be caused 4 Neck Disability by musculoskeletal dysfunction of the neck. Initial Pain = 4/10 Initial Evaluation Index Score: 58% 1 2 Acknowledgements Following o The structures that may be involved include C1, Initiated soft tissue (07/11/19) Treatment = 2/10 C2, and C3 vertebrae as well as the joints, discs, mobilization o Matthew Somma PT, DPT, MTC, CSCS for his assistance and support throughout the case report writing process. Matthew Ross PT, DPT Initiated Initial Pain = 4/10 ligaments, and musculature of the upper cervical Visit #1 therapeutic for assistance and supervision of patient care during the 2nd clinical 5 (07/18/19) exercise and Following spine. suboccipital release Treatment = 0/10 practicum. The patient for his participation in this case report. o Symptoms of CGH may include unilateral head and Initial Pain = 5/10 Visit #2 No intervention face pain, with pain localized to the occipital, Following 3 4 changes (07/20/19) Treatment = 0/10 temporal, or orbital regions, a moderate to severe References Patient called to Physical Therapy 1. Palma S, Bovo R, Benatti A, et al. Mastoiditis in adults: a 19-year retrospective study. Eur Arch pain intensity, restricted active and passive Referral to PCP cancel appointment referred patient 4 Otorhinolaryngo. 2013;271(5):925-931. doi:10.1007/s00405-013-2454-8 cervical range of motion. (07/24/19) and reported non- back to his Primary 2. Hongisto AL, Jero J, Markkola A, Saat R, Aarnisalo AA. Severe acute otitis media and acute remitting headache Care Provider mastoiditis in adults. J Int Adv Otol. 2016;12(3):224-230. doi:10.5152/iao.2016.2620 o Symptoms are likely triggered by head and neck MRI revealed 3. Abid W, Gamra OB, Ghorbal H, et al. Management of acute mastoiditis in children. A retrospective Patient’s primary infection in study and literature review. Egypt J Ear Nose Throat Allied Sci. 2014;15(3):205-209. movement, sustained or awkward neck posture, pare provider doi:10.1016/j.ejenta.2014.05.001 MRI (07/25/19) patient’s left 5 6 4 scheduled an MRI 4. Biondi DM. Cervicogenic headache: Diagnostic evaluation and treatment strategies. Curr Pain Mastoid and pressure applied to the cervical spine. Headache Rep. 2001;5(4):361-368. doi:10.1007/s11916-001-0026-x o CGH are managed pharmacologically, osteopathic, Patient was Patient was no 5. Becker WJ. Cervicogenic Headache: Evidence That the Neck is a Pain Generator. J Headache Pain. Discharge scheduled for longer appropriate 2010;50(4):699-705. doi:10.1111/j.1526-4610.2010.01648.x manipulative treatment, physical therapy, and (07/27/19) Mastoidectomy for physical therapy 6. Blanpied P, Gross A, Elliot J, et al. Neck Pain Guidelines: Revision 2017: Using the Evidence to Guide 4 surgery and was discharged Physical Therapist Practice. J Orthop Sports Phys Ther. 2017;47(7):511-512. possibly surgery. 1. Suboccipital Release 2. Scapular Retraction 3. Cervical Flexion AROM 4. Cervical doi:10.2519/jospt.2017.0507 Extension AROM 5. Cervical Rotation AROM 6. Cervical Side-bend AROM