Mild Bulging

A 5-year-old female is brought into the pediatric clinic by her mother with concern for right-sided ear pain. The pain began about a day ago and has been managed well with over-the-counter analgesics. Prior to the pain developing, the child had several days of viral symptoms including cough and rhinorrhea. On exam, the child appears unwell, but not toxic. She interacts appropriately. She has a normal temperature and evidence of a runny nose. A frequent cough is noted. The child does not have a history of ear infections. The Wispr digital otoscope exam of her right ear is shown.

What is the next step in management?

A. The child has mild acute otitis media (AOM) and a delayed prescription for antibiotics should be considered.
B. The child has a middle ear effusion; no further care is required.
C. The child has bullous myringitis and antibiotics should be started.
D. The child should be referred to otolaryngology (ENT) for ear tube placement.

Answer: A

The air-fluid levels present in this image indicate a middle ear effusion and the presence of bulging with the loss of bony landmarks suggests pressure is building in the middle ear space. On this child's Wispr exam, only the short process of the normally prominent malleus is visible. Also termed the lateral process, locating this landmark is a key step in assessing the tympanic membrane (TM). When acute otitis media is first developing, bulging initially occurs near the lateral process, making its appearance less distinct. With mild bulging, the diagnosis of acute otitis media (AOM) is not certain since this can occur in both evolving or resolving AOM as well as fever or crying.  Additional signs or symptoms including distinct erythema, pain, fussiness, or fever of > 39 C can help determine treatment. Based on the American Academy of Pediatrics guideline, this child's presentation with mild bulging, no fever, and pain well-controlled would be considered non-severe AOM. In a 5-year-old with non-severe AOM, the AAP guidelines are 48 to 72 hours of observation with the option for a delayed antibiotic prescription. These guidelines can be found here. It is notable this child's TM also has a normal appearing light reflex suggesting the membrane itself is fairly translucent. It is this author's opinion that translucency and evidence of a well-ventilated middle ear space is a good indication this non-severe AOM will resolve without antibiotics (therefore answer B is also acceptable!)

Bullous myringitis is a severe form of AOM whose hallmark is blistering of the tympanic membrane (TM). Because the child has no history of AOM and the mildness of this presentation, there is no indication for referral to otolaryngology for ear tubes.

WiscMed has created a visual diagnosis guide to the most common ear presentations that can be found here.

Key Learning Points:

1. Mild bulging of the TM is suggested by fullness of the pars flaccida (upper portion) of the membrane resulting in an indistinct appearance of the lateral process.
2. Mild bulging can be seen in either evolving or resolving AOM as well as in children with fever.
3. Non-severe AOM may be managed with 48 to 72 hours of observation and consideration of just-in-case antibiotic prescription. 

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