CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
6-year-old Fall from Balcony
A 6-year-old boy presented to the emergency department (ED) via ambulance after falling from a second-story balcony. The fall was unwitnessed, but Mom heard the child scream shortly after he went onto the balcony. She ran outside and found her son lying motionless on the concrete sidewalk. It is unclear if there was a loss of consciousness; however, the child started crying when his mother reached him. 911 was called, and the child was transported to the ED, where he underwent a trauma evaluation. Initial vital signs were appropriate for age, and his primary survey demonstrated a patent airway, clear breath sounds, no obvious source of bleeding, and a GCS of 15. His secondary survey was notable for superficial abrasion to his left cheek. The tympanic membranes (TMs) viewed with an analog otoscope were “difficult to see…maybe a little dark.” Re-examination of the TMs was performed with the Wispr digital otoscope, and the image is shown.
Which of the following is/are true regarding this child’s injury?
A. He likely has a fracture to the temporal bone
B. His otoscopic findings result from injury to branches of the maxillary artery
C. Penetrating trauma is the most common cause
D. A & B
Answer: D. A & B
This child’s Wispr digital otoscope exam demonstrates a classic appearance of a hemotympanum, or blood behind the tympanic membrane (TM). In this case, there appears to be a blood-air level present. The middle ear space is richly supplied by branches from the maxillary artery, including the anterior tympanic artery that runs through the petrotympanic fissure. This anatomic course makes the thin vessel susceptible to tearing with basilar (i.e., petrous portion) temporal bone fractures. These fractures most commonly result from blows to the head, such as from a fall or motor vehicle collision. Penetrating trauma accounts for less than 10% of cases.
Without proper visualization of the TM, a hemotympanum may be missed. In this case, the initial view with a traditional otoscope did not reveal the diagnosis. While many cases of basilar skull fractures are associated with additional injuries, the remainder of this patient’s primary and secondary survey was unremarkable. Re-examination with the digital otoscope provided the necessary view to confidently identify the hemotympanum. This aided in the evaluation of the child’s tympanic bone fracture. It is notable that the resident doctor’s evaluation of the TM as “maybe a little dark” suggested he indeed saw the hemotympanum, but the fleeting view and lack of experience interpreting this finding impacted his confidence. Given the limitations of analog otoscopy and hemotympanum appearance variability this is not surprising and further supports the use of digital otoscopy to impart competency in evaluating and diagnosing middle ear conditions.
