2-year-old with a Cough

A 2-year-old female presented to Urgent Care for evaluation of cough and congestion. Her parents reported their daughter had a runny nose for the past week and a cough that started the previous evening. In addition to poor sleep due to the cough, the child developed a low-grade fever that morning, so her parents brought her in for evaluation. Upon physical exam, the child was afebrile and well-appearing. Her Wispr digital otoscope exam is shown.

Which of the following describes this child’s tympanic membrane (TM)?

A. This is her left TM, and it is severely bulging.
B. This is her left TM, and it has a purulent effusion.
C. This is her right TM, and it is mildly bulging.
D. This is her right TM, and there is no effusion.

The Wispr otoscope image is from her left TM. This is confirmed by the position of the lateral process of the malleus, which can be observed as a small white bump in the upper left side of the TM.  Note that the lateral process is barely visible due to the bulging of the pars flaccida, which is the first portion of the TM to bulge when inflammation and middle ear pressure increase. While this obscuring of the malleus supports the presence of bulging, the degree would be considered mild, as it has not yet progressed to an “angry donut” appearance.   Based on AAP guidelines, this child would not be treated with antibiotics. Often, when severe bulging is present, the lateral process may not be visible at all, which can make laterality identification challenging.  This child’s TM demonstrates an air-fluid level inferiorly as well as a whitish film around the periphery—both signs of a purulent effusion.

Familiarity with TM landmarks is an important clinical skill that will aid in recognizing normal versus abnormal findings. Given its attachment to the TM, the malleus is a key landmark providing information about the laterality as well as the presence of membrane bulging or retraction.

Here is the complete video exam.