3-year-old Male with Ear Pain

A 3-year-old male presented to the pediatric clinic for evaluation of ear pain. Mom reported the child had been crying and holding his ear that morning. The prior night, he had been restless and felt warm, so he was given a dose of ibuprofen. In clinic, his temperature was 102.4^oF.  He was nontoxic but uncomfortable. His Wispr digital otoscope exam is shown.

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

A. He has a left acute otitis media (AOM)
B. He has a right AOM
C. He has a left otitis media with effusion (OME)
D. He has a right OME

The digital otoscopy image is from the child’s left ear and demonstrates bulging of the tympanic membrane (TM). The degree of bulging does not quite reach the classic “angry donut” appearance associated with moderate-to-severe bulging and is therefore more appropriately classified as mild, although a reasonable argument could be made for moderate bulging. WiscMed has created a guide to AOM and treatment.

Regardless, because the child has had less than 48 hours of ear pain, the combination of mild TM bulging and recent-onset otalgia meets the AAP diagnostic criteria for acute otitis media (AOM). Given the presence of mild bulging and fever, antibiotics should be considered.

American Academy of Pediatrics (AAP) Diagnostic Criteria for AOM

Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. Clinicians should diagnose AOM in children who present with mild bulging of the TM and recent (less than 48 hours) onset of ear pain (holding, tugging, or rubbing of the ear in a nonverbal child) or intense erythema of the TM.                                        

Clinical Pearl: Determining Which Ear

Recall that the orientation of the malleus can help determine whether you are viewing the right or left TM. Think of the malleus as the hand of a clock, pointing toward the side of the ear being examined.

When the TM is bulging, however, the malleus may become difficult to identify. In these cases, look for the prominent vasculature coursing along the malleus, which often remains visible and can serve as an additional landmark for identifying its orientation and determining laterality.