CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
Ear Pain and Fever in a Toddler
A 3-year-old child presented to the ED with left ear pain and a fever to 103°F. She had a runny nose for about a week, but no ear pain or fever until that evening. Her mother stated the child underwent “ear tube placement” for recurrent infections the previous year, but she currently had no ear drainage. The child’s last ear infection was shortly after the tympanostomy tube (TT) placement and was treated successfully with ciprofloxacin drops. The Wispr Digital Otoscope exam of her left ear is shown.
Which of the following best describes the child’s findings?
A. She has moderate to severe bulging of the tympanic membrane (TM)
B. She has mild bulging of the TM
C. Her tympanostomy tube appears to be non-functioning
D. A and C
Answer: D. A and C
The child’s TM has moderate to severe bulging as evidenced by its “angry donut” appearance. This finding occurs as inflammation and middle ear pressure progresses, causing the TM to bulge outward from the centrally fixed attachment of the umbo. Note how the lateral process of the malleus is visible only as a small white point due to bulging in the pars flaccida. Also, note the presence of a purulent middle ear effusion (MEE), yet there is no drainage from the tympanostomy tube (TT). This suggests the tube is occluded or partially extruded.
If a TT becomes clogged, fluid no longer drains from the middle ear, and pressure (bulging) and discomfort increase. Younis(1) has published a guide to managing plugged tympanostomy tubes. Dr. Younis notes that the plugging material is generally from the inflammatory middle ear fluid, not cerumen. Attempting to mechanically clear the tube is painful, traumatic, and generally not successful. Hydrogen peroxide drops clear the blockage 85% of the time. Because there is evidence of AOM in this case, antibiotics should be considered.
WiscMed has published a visual diagnosis guide to common ear conditions. This guide can be downloaded as a pdf here.
Key Learning Points:
- Moderate to Severe TM Bulging ("Angry Donut" Sign) – The tympanic membrane (TM) in acute otitis media (AOM) can bulge outward significantly due to increased middle ear pressure. The “angry donut” appearance occurs when the TM expands around the umbo, obscuring normal landmarks like the lateral process of the malleus.
- Non-Functioning Tympanostomy Tube (TT) – The presence of a purulent middle ear effusion (MEE) without drainage from the TT suggests the tube is either occluded or partially extruded, making it ineffective in relieving pressure and drainage.
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