Acute Otitis Media

Answer: A. He has a right acute otitis media (AOM)

This child’s Wispr exam demonstrates moderate to severe bulging of the tympanic membrane (TM) as evidenced by the presence of a classic “donut” sign, resulting when bulging progresses circumferentially around the umbo, the central point of attachment of the malleus to the TM. The presence of the donut sign indicates moderate to severe bulging and allows a confident diagnosis of AOM (AAP Guideline, see Seeing is Believing Part 2). What is less obvious is determining which TM is being viewed, left or right. Upon close inspection of the image, the tip of the lateral process can just barely be identified in the upper righthand aspect of the TM (roughly 3 o’clock).  The lateral process is a useful landmark since its location points toward the side of the TM in question. In this case, the location is in the upper right side, thus this is the child’s right TM.

Compare this case of acute otitis media with a normal right eardrum.

Bullous myringitis may be considered a more severe form of acute otitis media. In addition to the bulging found in AOM, bullous myringitis includes blistering on the TM.

WiscMed has created a visual guide to various ear conditions that may be found here.

Key Learning Points:

1. The donut sign indicates moderate to severe bulging of the tympanic membrane and allows a confident diagnosis of AOM.
2. The lateral process of the malleus points toward the side of the TM in question.
3. With moderate to severe bulging, the lateral process of the malleus may be difficult to identify. Knowledge of the expected position (upper left or upper right) will help locate this landmark.

References

Lieberthal, Allan S., et al. "The diagnosis and management of acute otitis media." Pediatrics 131.3 (2013): e964-e999