14-month-old with Ear Pain

A 14-month-old child presented to the emergency department (ED) for evaluation of ear pain. Her mother reported that the child was started on antibiotics the day prior, but the child continued to put her finger into her ear. The mother interpreted this as discomfort, so she sought re-evaluation since her daughter had multiple ear infections and “probably needs ear tubes.” In the ED, the child appeared well and was afebrile. Her Wispr digital otoscope exam is shown.

Which of the following is true regarding this child’s ear findings?

A. The tympanic membrane is mildly bulging
B. The tympanic membrane is retracted
C. The child has a purulent middle ear effusion
D. The child should continue her antibiotic

The child’s tympanic membrane (TM) is retracted as evidenced by the very prominent lateral process of the malleus. This retraction is caused by negative pressure within the middle ear space, resulting in the TM being “sucked” inward, accentuating this bony landmark. One can also appreciate several air-fluid interfaces with an amber-appearing middle ear effusion (MEE). Unlike acute otitis media (AOM) where bulging and a purulent MEE are present, this child’s findings are most consistent with otitis media with effusion (OME)—if one wishes to be specific, it could be labeled “chronic” otitis media with effusion (COME) since it is felt the amber appearance occurs later in the resolution of a MEE.  Regardless of the timeframe, this child does not require antibiotics, and they should be discontinued. Her OME is likely either a resolving AOM and/or from an upper respiratory virus with ongoing Eustachian tube dysfunction, with some discomfort causing the child to “stick her fingers in her ear”.  Resolution of this MEE ought to be documented within three months. If still present, referral to otolaryngology (ENT) for hearing assessment and potential tympanostomy (ear, ventilation) tube placement would be warranted.

Here is the complete video exam