CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
4-year-old with a Cough
A 4-year-old presented to her pediatrician’s office for cough, congestion, and fever. The child’s mother reported approximately five days of symptoms with a temporal fever measured as 101o F the prior day. She intermittently complained of ear pain since the start of her illness and “felt warm” the morning of presentation. In the clinic, she was afebrile with normal vital signs. She had yellow rhinorrhea and clear breath sounds. Her Wispr digital otoscope exam is shown.
Which of the following is (are) correct regarding this child’s presentation?
A. She has moderate to severe bulging of the tympanic membrane (TM) and should be started on antibiotics immediately.
B. She has moderate to severe bulging of the TM and should be offered an antibiotic prescription to start in 48 to 72 hours if not improve clinically.
C. She has mild bulging of the TM and should be started on antibiotics immediately.
D. She has mild bulging of the TM and should not be started on antibiotics.
Answer: D. She has mild bulging of the TM and should not be started on antibiotics.
The child’s Wispr digital otoscope exam demonstrates mild TM bulging as evidenced by the slight depression centrally (umbo dimple) and difficulty visualizing the lateral process of the malleus superiorly (due to pars flaccida bulging). Recall that bulging is initially observable in the pars flaccida (thus obscuring the lateral process) and extends circumferentially around the fixed attachment of the umbo, giving a “full” appearance of the TM. This contrasts with the “angry donut” appearance of moderate to severe bulging. The presence of mild bulging alone is not sufficient to confidently make a diagnosis of acute otitis media (AOM), as it may be observed in multiple scenarios, including the crying child, otitis media with effusion (OME), fever, or early Eustachian Tube Dysfunction.
Thus, according to the AAP Clinical Practice Guideline:
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, rubbing of the ear in a nonverbal child) or intense erythema of the TM.
The child in this case had complained of intermittent ear pain for several days, and her TM is not erythematous. The child was diagnosed with an URI, and supportive care with follow-up if symptoms worsened was recommended. Some clinicians may consider providing a just-in-case antibiotic prescription, but there is no indication for immediate antibiotics.
WiscMed has created a guide to the treatment of acute otitis media, which can be found here. In addition, a visual guide to common ear pathology can be found here.
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