CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
43-year-old with Ear Pain
A 43-year-old presented to the Emergency Department (ED) for ear discomfort. She had no fevers, nasal congestion, or other respiratory symptoms. She reported a history of occasional ear infections as well as seasonal allergies, “which have been acting up.” Her evaluation was unremarkable except for her Wispr digital otoscope ear exam, which is shown.
Which of the following is true regarding her tympanic membrane (TM) finding?
A. The TM has good mobility
B. There is retraction of the pars flaccida region of the TM
C. There is diffuse tympanosclerosis
D. All of the above
Answer: D. All of the above
The patient’s TM appears abnormal and requires a systematic approach to assess the findings. Given her presentation for ear discomfort, the initial determination is whether she has an acute otitis media (AOM). The TM does not demonstrate moderate to severe bulging, (ie does not look like an angry donut) and there is no “fullness” to suggest even mild bulging. Thus, it is very unlikely her symptoms are due to AOM.
The lateral process of the malleus is very prominent, a finding often observed when the TM is retracted. This patient has retraction of the pars flaccida. While this is an area that may progress to a deeper retraction pocket or contain debris suspicious for cholesteatoma, this portion of the TM appears clean.
Most of the TM appears “whitish”. This can be from a middle ear effusion (MEE), , resolving AOM, or tympanosclerosis/general thickening of the TM (calcification deposition within the TM). When the TM is not translucent enough to evaluate for MEE, several options exist to evaluate. Tympanometry, pneumatic insufflation, and Eustachian tube clearance. This patient performed an ear clearance maneuver (Valsalva) that resulted in clear mobility of her TM—making a MEE less likely (see video below to observe TM movement during Valsalva).
The assessment is this patient’s TM lacks bulging and demonstrates pars flaccida retraction. The diffuse whiteness without evidence of MEE suggests tympanosclerosis/thickening. Overall, this constellation of findings is likely due to chronic Eustachian tube dysfunction and may be exacerbated by the patient’s recent increase in seasonal allergy symptoms.
Here is the complete video of the ear exam. Note the mobility of the tympanic membrane when the patient performs the Valsalva maneuver.
