Bullous Myringitis

Jan 16, 2025

A 4-year-old child presented to the emergency department (ED) with left ear pain for one day. His mother reports the child has had a cough and congestion but no fever. He went to bed a little earlier than was usual for him but awoke shortly after crying in pain. In the ED, he is in obvious discomfort with a hand over his left ear. His vitals are notable for mild tachycardia. He has nasal congestion with yellow rhinorrhea.

His WiscMed Wispr digital otoscopic exam is shown.

Which of the following is correct regarding the child’s condition?

A. He has a foreign body that will require removal
B. Oral antibiotics are not indicated
C. Topical antibiotics are indicated
D. Pain control can be managed with topical anesthetic

Answer: D . Pain control can be managed with topical anesthetic

The child in this case has bullous myringitis, a variant of acute otitis media (AOM) in which the tympanic membrane (TM) develops blisters. It looks painful, and it is. The bulla in this child’s left ear was so severe that the clinician’s initial impression was for the presence of a bead or similar foreign body. However, after review of the video (below), it is quite clear that the child has an impressive bulla (blister) that is distorting his TM. The etiology of bullous myringitis is like other AOM pathogens, namely Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Additional causative agents are respiratory viruses and mycoplasma pneumoniae. Treatment is with oral antibiotics along with pain control. Topical anesthetic drops such as proparacaine can provide immediate relief and a bridge until oral pain medications take effect.

Key Learning Points:

Bullous myringitis is a variant of AOM and is caused by similar infectious pathogens.
Blistering in bullous myringitis can be impressive and make identification of TM landmarks impossible.
Oral antibiotics and topical pain medications are indicated for management.

CLINICAL CASES

Bullous Myringitis

Prescribe Less Antibiotics in 2025