CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
5-year-old with a Fever and Ear Pain
A 5-year-old presented to the emergency department (ED) for fever and ear pain. Her mother reported the child complained of ear pain “all night” and had an oral temperature of 104oF early that morning. She received a dose of ibuprofen that helped with both the fever and ear pain. The child’s past medical history was significant for occasional viral illnesses with one prior acute otitis media (AOM). The family planned to travel by airplane for spring break that evening, so they decided to have her evaluated. In the ED, the child was tearful but afebrile and nontoxic. Her Wispr digital otoscope exam is attached.
Which of the following is the most appropriate course of action:
A. Perform bulb insufflation to evaluate for a middle ear effusion (MEE)
B. Provide options for pain relief
C. Prescribe an antibiotic to treat AOM
D. B & C
Answer: D. B & C
The child can be confidently diagnosed with bilateral acute otitis media (AOM) due to the presence of bulging as well as the new onset of ear pain. While the bulging may not quite reach the level of the “angry donut” sign observed in severe bulging, the diagnosis is further supported by the prominent vasculature causing the TMs to appear injected along the periphery and body of the malleus. Treatment with antibiotics is warranted, given the child had a fever exceeding 102.2oF and reportedly experienced significant ear pain interfering with sleep, indicating her case may be classified as severe. All diagnoses of AOM should include an assessment and plan for pain control, regardless of whether antibiotics are indicated. In this case, ibuprofen was advised, as well as topical proparacaine drops for local anesthetic immediately before travel by airplane.
Both of the child’s tympanic membranes had a similar appearance, thus she has bilateral AOM. Based on her assessment of the severe AOM, the treatment is the same for unilateral or bilateral AOM.
While the American Academy of Pediatrics (AAP) guidelines and others rely heavily on bulging as a key indicator in AOM, the guidelines make note of pneumatic otoscopy or tympanometry to evaluate for middle ear effusions (MEE). It has been argued that pneumatic insufflation is problematic in children with AOM as it is uncomfortable and not routinely performed by clinicians skilled in the technique. Notably, these recommendations were published before advancements in digital otoscopy greatly enhanced the direct visualization of TM pathology. Thus, when air-fluid levels or bubbles are noted in a bulging TM, there is no advantage to utilizing pneumatic otoscopy to diagnose AOM. In instances where the TM is not bulging (i.e., unlikely to be AOM) but is opaque (which may block the visualization of an MEE), then insufflation or tympanometry would be useful as an adjunct to evaluate for otitis media with effusion (OME).
AAP Guidelines Key Action Statements addressed by this case:
-Key Action Statement 1B: 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.
-Key Action Statement 1C: Clinicians should not diagnose AOM in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/or tympanometry).
-Key Action Statement 2: The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.
-Key Action Statement 3A: Severe AOM: The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher).
WiscMed has created a handy wall reference to the diagnosis and treatment of AOM that may be found here.
Below are the complete videos of both ears.
References
