CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
3-year-old with a Fever
A 3-year-old child was brought to the Urgent Care for evaluation of fever and congestion. The mother reported her daughter had been ill for “at least a month” with a runny nose. Her activity level was normal until the prior evening, when she developed a fever of 100.5 oF. She had an occasional cough and received an albuterol neb (her older brother’s medication) just before arrival due to concern she was wheezing. The mother denied excessive crying, fussiness, holding her ear, or other signs of pain. The child attended pre-school, where multiple children had been ill. Upon evaluation, she was afebrile with age-appropriate vital signs. She had clear rhinorrhea with mildly coarse breath sounds bilaterally. Her Wispr digital otoscope exam is shown.
Which statement best describes the otoscopic findings and appropriate management?
A. Mild bulging of the tympanic membrane (TM); Prescribe antibiotics to start immediately
B. Mild bulging of the TM; Supportive management with follow-up as needed
C. Severe bulging of the TM; Prescribe antibiotics to start immediately
D. Severe bulging of the TM; Supportive management and a just-in-case antibiotic prescription to start if symptoms worsen over the next 48 hours.
Answer: B. Mild bulging of the TM; Supportive management with follow-up as needed
The child in this case has an abnormal TM—it has a dull appearance, there is no light reflex, and there appears to be whitish thickening and/or middle ear effusion (MEE) along the periphery. All these findings may give one an impression of a bacterially infected TM (i.e., AOM) requiring immediate antibiotic prescription. However, evidence suggests these findings are also observed in otitis media with effusion (OME) and pale in comparison to bulging as an indicator for acute otitis media (AOM).
Accordingly, the AAP Clinical Practice Guidelines recommend:
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 may 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.
This child’s TM is best described as mild bulging. Recall that in severe bulging, the TM takes on the appearance of an angry donut with a deep central depression and often a total loss of malleus visibility. With mild bulging, the malleus is indistinct, but still identifiable, and the central TM has a shallow dimple. Given this child’s mild bulging as well as lack of ear pain or intense erythema, the diagnosis of AOM is not certain, and antibiotics should not be initiated. In such instances, supportive therapy is recommended with follow-up if symptoms worsen.
WiscMed has created a guide to the diagnosis of acute otitis media (AOM), which can be found here.
Here is the video exam of the right ear.
