Bullous Myringitis

An 8-year-old female presented to the emergency department (ED) with left ear pain that woke her from sleep. She had two days of nonproductive cough and reported mild pain earlier in the evening that improved with ibuprofen. However, shortly after going to bed, the pain increased significantly so she was brought in for evaluation. Of note, the child’s chart noted an allergy to amoxicillin. Upon questioning, her mother reported “hives all over” when she was prescribed amoxicillin for a previous ear infection. In the ED, the child was afebrile with normal vital signs. Her physical exam demonstrated nasal congestion without rhinorrhea and clear to auscultation lungs. Her Wispr digital otoscope exam is shown. 

Which of the following is the most appropriate management plan?

A. Treat with high-dose amoxicillin for 5 days
B. Treat with high-dose amoxicillin for 10 days
C. Treat with azithromycin for 5 days
D. Treat with ofloxacin drops for 7 days

It is not surprising this child presented to the ED for ear pain. Her Wispr exam demonstrates moderate to severe bulging of the tympanic membrane (TM) as well as two small bullae centrally. Her diagnosis of acute otitis media (AOM) with bullous myringitis is certain and treatment with antibiotics is appropriate. Given her history of presumed IgE-mediated allergic reaction (hives) with amoxicillin, an alternative agent should be chosen. Ofloxacin, a topical fluoroquinolone is not an option unless tympanostomy tubes are in place. The macrolide azithromycin, while it has its limitations against H. influenza and certain S. pneumoniae strains, is the best alternative in this penicillin-allergic patient.

WiscMed has created a visual diagnosis of ear pathology that may be found here.

Key Learning Points

1. Bullous myringitis can be considered a “severe” case of acute otitis media with the distinguishing characteristics of bullae (blisters) on the TM.
2. Azithromycin is a good alternative for treating bullous myringitis in penicillin-allergic patients.