14-month-old with Fever and Cough

A 14-month-old presented to his pediatrician’s office with concern for fever and cough. His parents reported the cough was “constant since starting daycare,” and he had a subjective fever the previous evening. In the clinic, his temperature was 36.5 °C, respiratory rate 55, and oxygen saturation 92% on room air. His HEENT exam was notable for clear rhinorrhea. His respiratory exam revealed subcostal retractions and diffuse wheezes. His Wispr Digital Otoscope exam is shown.

Which of the following is true regarding his tympanic membrane (TM) findings?

A. He has acute otitis media (AOM) and should be started on oral antibiotics.
B. He has evidence of a recent ear infection
C. His TM is severely bulging 
D. All the above

The child’s TM has findings suggesting a recent infection. Much of the TM is dull and lacking a light reflex. In addition, there are several “spots” of mucopurulence with prominent overlying blood vessels (see annotated image). These small patches can be observed in the weeks following acute infection and are felt to be areas of inflammation reabsorption. Found in approximately 50% of recently infected TMs, they are typically located along the inferior periphery and should not be mistaken for pathology requiring antibiotics.  While there may be some mild fullness of this child’s TM in the pars flaccida region, it does not have the “angry donut” appearance of moderate to severe bulging observed in acute otitis media. There is an air-fluid level suggesting that the Eustachian tube is properly ventilating the middle ear space.

Reference:

Michael D. Poole, MD, 2019 Otitis: The Expert’s Diagnostic Guide