Healthy 28-year-old with Ear Finding

A healthy 28-year-old woman with no hearing complaints has a routine ear exam. The following image is obtained with the Wispr digital otoscope.

What is the finding of note, and what is the next step in management?

A. Infection, start antibiotics
B. Benign fibrous markings, no action needed
C. Tympanic membrane rupture, urgent consult to otolaryngology (ENT)
D. Chronic allergies, begin a course of steroids

The woman has fibrous markings on her tympanic membrane (TM, eardrum). The TM is made up of three layers of cells. The middle layer is fibrous, provides the “strength” of the TM, and is responsible for the TM's response to sound waves. This middle layer can have both radial and circular fibers. They are generally not visible with otoscopy, but in some cases such as this, it is possible to see what are most likely radial fibers. The markings may also represent past scarring of the TM. The finding has no clinical significance and does not affect hearing.

The patient does not have an infection. An infection such as acute otitis media presents as an “angry donut.” There is no evidence of a rupture to the TM. The presentation of the TM is not consistent with chronic allergies, which may present as haziness of the entire TM.