Acute Otitis Media (AOM)

A 2-year-old child presented to the pediatric emergency department (ED) with fussiness and ear pain. His mother reported her son had a cough for a week but had been doing well until that evening. He awoke crying and holding his right ear. His mother reported no change in appetite or any other GI symptoms. The child received a dose of ibuprofen prior to arrival. In the ED, the child is tearful, his temperature was 100.5^oF with otherwise age-appropriate vital signs. He had yellow rhinorrhea, his oropharynx was without erythema or lesions, and his lungs were clear to auscultation.  His WiscMed Wispr digital otoscopic exam is shown.

Which of the following describes the child’s Wispr otoscope findings?

A. Normal
B. Retracted
C. Mild bulging
D. Moderate to severe bulging

Answer D. Moderate to severe bulging

This child’s tympanic membrane (TM) demonstrates moderate to severe bulging as evidenced by the “donut sign.”  Bulging indicates inflammation and a middle ear effusion (MEE). It is the hallmark of acute otitis media (AOM). Bulging is the most important distinguishing feature of AOM from otitis media with effusion (OME). The importance is that AOM generally requires treatment and OME does not. Recognition of bulging is an important skill for clinicians to accurately diagnose between these two conditions.

 Bulging occurs initially in the posterosuperior quadrant (the pars flaccida) where the TM is most compliant, often making the lateral process of the malleus less distinct. This would be mild bulging. As the pressure in the middle ear space increases, the umbo dimple (donut) appears. Both findings give the TM a “full” appearance in mild bulging.  When progression occurs to moderate/severe, the bulging results in the “donut sign” with a deeper central umbo creating the “donut hole.”

According to the AAP Clinical Practice Guideline

Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. 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.

 WiscMed has created both a visual diagnosis to ear conditions and an AOM treatment guide.

 The child in this case fits easily into the diagnostic recommendations for AOM and was started on amoxicillin after receiving topical proparacaine drops in the ED. He was more comfortable following pain control and discharged with careful return instructions.

 While bulging makes the lateral process indistinct, retraction of the TM often makes it more prominent. This is an indicator of negative pressure in the middle ear due to Eustachian tube dysfunction, a condition that may also cause ear pain or discomfort. This reinforces the importance of the physical findings in managing children with ear pain.

Key Learning Points

1. Acute Otitis Media’s (AOM) hallmark is the bulging of the tympanic membrane that produces an angry-appearing red donut sign.
2. AOM can be painful, topical pain control is helpful as antibiotics are initiated.