CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
7-year-old with Ear Pain
A 7-year-old presented to Urgent Care for evaluation of ear pain for the past four days. Mother reported the child had congestion and cough for a week and occasionally complained that her right ear was bothering her, including the morning of presentation. She had a fever of 103oF at the onset of her congestion, but none for the preceding four or five days. She has a history of recurrent acute otitis media (AOM), so her mother wanted to “make sure she didn’t have another one.” Her last AOM was several months prior to presentation. The child was afebrile and in no acute distress. She had copious, clear rhinorrhea. Her Wispr digital otoscope exam is shown.
Which of the following is true regarding this child’s clinical presentation?
A. Her left tympanic membrane (TM) is mildly bulging and has a middle ear effusion (MEE)
B. Her right TM is mildly bulging and has a MEE
C. Her left TM is mildly bulging and consistent with acute otitis media (AOM)
D. Her right TM is severely bulging and is consistent with AOM
Answer: A. Her left tympanic membrane (TM) is mildly bulging and has a middle ear effusion (MEE)
This child’s Wispr digital otoscopic exam demonstrates several common findings that are important to recognize when evaluating a child with ear pain. The left TM has a slightly cloudy MEE with several visible air-fluid levels. Although there is mild bulging in the pars flaccida, the pars tensa does not appear to be bulging as the malleus is quite easy to identify with the lateral process, body, and umbo all visible. The lack of pars tensa bulging in the presence of a MEE indicates the child has a left otitis media with effusion (OME), but not AOM.
The pars flaccida lacks the medial fibrous layer found in the pars tensa portion of the TM, making it more susceptible to movement with middle ear pressure or inflammation. Thus, even when mild bulging occurs, it is noted in this superior portion (i.e., near the lateral process of the malleus). As bulging progresses to moderate/severe, the remainder of the TM is affected and takes on the “angry donut” appearance. This child’s TM is bulging only in the pars flaccida region and has a cloudy-appearing MEE.
Given the finding of a MEE with mild bulging, the diagnosis of AOM generally requires a more abrupt onset of ear pain or fever less than 48 hours or intense erythema. Close inspection does reveal some injection to the TM; however, with the ear discomfort occurring intermittently for “four to five days” and no recent fever, it was felt this likely represented spontaneously resolving AOM. Review of the TM findings was performed with the mother, and supportive care was recommended with close follow-up if fevers returned or pain became more persistent.
WiscMed has prepared a visual guide to common ear conditions that can be found here.
