5-year old with Severe Ear Pain

A 5-year-old male presented to the pediatric clinic with ear pain. The child recently started school, and his father reported several classmates had been diagnosed with a respiratory syncytial virus (RSV). Three days ago, the child developed a cough, fever, runny nose, and congestion. The parents treated the symptoms with over-the-counter medications, but overnight, he was crying and holding his ear. His Wispr digital otoscopic exam is pictured below.

Which of the following is true regarding the child's tympanic membrane (TM) finding?

A. Findings are consistent with bullous myringitis
B. Viruses are the most common etiology
C. Ear pain is frequently severe
D. All of the above     

The child has bullous myringitis, characterized by blistering or bullae on the TM. This condition occurs predominantly in the setting of viral respiratory illness and is frequently quite painful. Bullous myringitis may be observed isolated to the TM as well as in the setting of an infected middle ear effusion. Thus, while RSV and influenza viruses are the most common pathogens, the usual suspects for bacterial acute otitis media (AOM), including Streptococcus pneumoniae and Haemophilus influenzae, may be present. Management may include antibiotics to cover for these bacteria, but attention to pain management is paramount.  

Compare the three examples below of a normal ear, an ear with acute otitis media, and an ear with bullous myringitis.  Treatment is focused on providing pain relief along with treating the underlying infection. An anesthetic such as topical lidocaine can be introduced in the ear canal to provide timely pain relief. Treatment of the underlying infection is the same as for acute otitis media. Historically, bullous meningitis was thought to be caused by Mycoplasma pneumoniae. However, as Mellick(1) documents in his letter, it is a component of severe AOM whose underlying cause may be a number of infectious agents. (1) Mellick and Verma, Letter, Pediatric Emergency Care, Volume 26, Number 12, December 2010