Resolving Acute Otitis Media (AOM)

Answer: C. She has evidence of a resolving acute otitis media and does not require antibiotics.

The child’s Wispr exam demonstrates a tympanic membrane (TM) that is mildly bulging and dull in color. This results in the malleus being difficult to appreciate (only the lateral process is visible) and a lack of light reflex. While no air-fluid levels or bubbles are obvious, this child very likely has a middle ear effusion (MEE). While mild bulging may be a finding in AOM, the 2013 AAP guidelines state that additional findings of intense erythema of the TM or recent onset of pain (holding, tugging, rubbing if the child is nonverbal) should be present. The child in this case has neither. However, her TM does demonstrate two patches of mucopurulence (mud spots) at the two and six o’clock positions. These patches are consistent with a resolving AOM that does not require antibiotics. Mucopurulence is thought to be a collection of leukocytes from resolving infection that are adherent to the middle ear surface of the TM. Here is a case series that shows the initial diagnosis of AOM through resolution including the development of mud spots. Ventilation (ear, tympanostomy) tubes are not indicated for resolving AOM.

 Key Learning Points:

1. Mucupurulent patches adhere to the internal (middle ear) surface of the TM.
2. Mucopurulence is a common finding in children with resolving AOM and otitis media with effusion (OME). It is an indication that the infection is resolving, and additional treatment is not required.
3. Small blood vessels may be visible around and within the patches and likely indicate a later phase of resolution.