CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
8-year-old with a Headache
An 8-year-old female was transferred to an academic pediatric emergency department (ED) from an outside facility for a head injury. She reportedly fell four feet off a playground climbing wall, striking the back of her head on the ground. She had no loss of consciousness but complained of a headache shortly after the incident. Her mother took her to their local ED. A head CT was performed after she had an episode of vomiting. The CT did not reveal injury; however, due to a persistent headache, she was diagnosed with a concussion and referred for further evaluation. In the academic ED, the child’s vital signs were normal, and she was well-appearing. Her exam was notable for mild swelling and tenderness posterior to her left ear. Her Wispr digital otoscope exam is shown.
Based on the patient’s presentation, which of the following is likely to be true?
A. She has a conductive hearing loss
B. She has a temporal bone fracture
C. Associated injuries may include facial nerve palsy or carotid vessel tears
D. All the above
Answer: D. All of the above
The child’s Wispr exam demonstrates a hemotympanum—dark blood is present behind the translucent tympanic membrane (TM, “eardrum”). The Emergency Medicine resident taking part in this patient’s care recognized “there was something wrong” with the TM and noted the malleus stood out more than usual—a result of the dark blood providing sharp contrast to the white ossicle. Hemotympanum is most often associated with blunt head trauma resulting in a fracture to the skull base, including to the complex temporal bone. As such, associated injuries can occur to structures coursing through the bone, including to the facial nerve and carotid artery. Due to fluid within the middle ear space, conductive hearing deficits are common—indeed, upon further questioning, the child reported “muffled” hearing from her left ear.
Given the Wispr findings, a temporal bone CT was performed that demonstrated the effects of her fall from four feet: trace pneumocephalus (intracranial air), fluid (presumed blood) in the left tympanomastoid air cells, and diastasis (widening) of multiple basilar skull sutures. Both the Pediatric ENT and Neurosurgery teams were consulted. Fortunately, the child’s exam remained overall reassuring, and she was ultimately assessed as stable for discharge with ENT and Audiology follow-up in six months.
