Erythema

A previously well four-year-old male was brought into the emergency department at 2 am by his parents with concern about ear pain. The child has had a cough, a runny nose, and a mild fever for nearly a week. The parents reported that multiple children at the daycare have been ill recently. They have been treating his symptoms with over-the-counter medications. On exam, the child appeared uncomfortable without being toxic. He had a temperature of 38 °C, appropriately resisted the exam, and was crying robustly. He had copious tears and oral secretions. His Wispr digital otoscope exam is attached below. 

Which of the following correctly describes this child's tympanic membrane (TM)?

A. It is moderately bulging
B. There is a small hemorrhagic blister
C. The TM demonstrates a normal light reflex
D. B & C

This child's TM appears quite injected with dilated blood vessels. Upon close inspection, there appears to actually be areas of hemorrhage with several tiny petechiae as well as a small blood-filled blister (see annotated image below). The TM is fairly dull and no light reflex is appreciated.  There appears to be some purulence and/or thickening on the membrane as evidenced by the whitish areas which contributes to the lack of translucency. Note that that there is no significant bulging as observed in a more classic case of acute otitis media (AOM). The bullae and petechia suggest inflammation within the membrane itself--such myringitis may occur independent of a purulent middle ear effusion, but the pathogens responsible are primarily the typical AOM culprits (respiratory viruses, Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Moraxella catarrhalis)  as well as Mycoplasma pneumoniae.