CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
4-year-old with Ear Pain
A 4-year-old presented to her pediatrician’s office with a complaint of fever and ear pain. She was positive for influenza via a home test earlier that morning and had been given ibuprofen for a fever to 104oF. Her fever improved, but she was crying due to ear pain, resulting in a care visit. Upon arrival, the child was afebrile in triage but felt subjectively warm. She was in moderate distress, holding her right ear. Her lungs were clear to auscultation, and the remainder of her physical exam was non-focal. The Wispr digital otoscope exam is pictured below.
Which of the following is true regarding this child’s clinical presentation?
A. Influenza is unlikely to be a cause of her otoscopic findings.
B. She should be referred immediately to ENT for management.
C. She should be managed with pain-control only.
D. None of the above.
D. None of the above.
The child’s otoscopic findings are consistent with bullous myringitis and acute otitis media (AOM). The distinction between the two conditions can be confusing because bullous myringitis is often thought of as “a type of AOM”. However, as their names imply-- bullous myringitis is specific to tympanic membrane (TM) blistering, while AOM involves the middle ear space with effusion (MEE) and inflammatory changes causing TM bulging. The confusion likely arises since the two conditions commonly occur together, as do their etiologic agents of mixed viral (ie influenza and RSV) and bacterial (ie. Streptococcus, H flu, Moraxella, mycoplasma) pathogens.
This child’s TM clearly has a blister in the posterior inferior quadrant. Also, her TM is moderately bulging (one can barely make out the lateral process of the malleus), and there is an air-fluid level with a purulent appearing MEE. Thus, she has both bullous myringitis and AOM, and ought to be treated with pain control as well as a course of oral antibiotics. Immediate referral to ENT is not necessary; she should be followed up closely if any hearing concerns persist.
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