CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
5-year-old with a Cough
A 5-year-old presented to the emergency department (ED) for a harsh cough and congestion. Her father reported a subjective fever but a relatively normal activity level. The child had a barky cough but no stridor on physical exam. She was afebrile and otherwise well-appearing. Her Wispr digital otoscope exam is shown.
Which of the following is/are true?
A. The child has a perforated TM
B. The child has a retraction pocket
C. The child likely has a history of tympanostomy tubes
D. B & C
Answer: C. The child likely has a history of tympanostomy tubes
The most obvious finding for this child is the presence of white plaque in the anterior aspect of the TM, consistent with myringosclerosis. This calcification of the TM (if middle ear structures are also involved, the term tympanosclerosis is preferred) is often observed following recurrent acute otitis media (AOM) and/or tympanostomy tube (“ear tube”, ventilation tube) placement. Further evidence supporting that this child had prior tube surgery is the oval-shaped thinning of the pars tensa immediately posterior to the plaque. At first glance, one may confuse this for a “hole,” but close inspection reveals a cone of light reflecting off the highly transparent membrane. The increased transparency of this area is due to a relative thinning of the TM, particularly of the middle fibrous layer which provides membrane strength and tension. Recall that the pars flaccida region of the TM lacks this fibrous layer and is prone to the development of retraction pockets. These appear as a localized prolapsed membrane in the superior posterior region of the TM. The location of the thinned area on this child’s TM is consistent with the location for tube placement. And upon questioning, the father confirmed she had ear tubes removed three months prior.
WiscMed thanks Pediatric ENT specialist, Dr. Tony Kille, for his assessment and input on this week’s case.
