CLINICAL CASES

Using the Wispr Digital Otoscope
Shagrination

Shagrination

A 4-year-old female presented to the Pediatric emergency department (ED) concerned about drainage from her right ear. Her mother states the child has had cough and congestion “all month” and awoke that morning with yellowish drainage on her pillow. She felt warm the evening prior to presentation but has not had a measured fever. However, she received a dose of ibuprofen before bed because her ear was hurting. In the ED, the child was afebrile and overall well-appearing. She had clear rhinorrhea. There was dried yellowish crusting to the right external auditory canal (EAC). Her WiscMed Wispr digital otoscopic exam is shown.

Which of the following describe(s) the tympanic membrane finding?

A. Bullous Myringitis
B. Shagrination
C. Exostosis
D. Sclerosis

Answer B. Shagrination

The child in this case has severe bulging of the tympanic membrane (TM) consistent with acute otitis media (AOM) with the typical “donut sign.”  Additionally, there is a speckled appearance to the anterior inferior quadrant that is classic for shagrination. Also known as cobble stoning, this is felt to result when a bulging TM is beginning to decompress—perhaps heralding resolution of AOM. Although no clear rupture of the TM was visible on exam, the presence of purulent crusting in the EAC and a small amount of dried blood at the inferior aspect of the TM suggests that there is likely a defect in the TM.  Given this finding, it is possible the rupture partially decompressed the middle ear space and contributed to the cobblestoned appearance of the TM.

Bullous myringitis is AOM with blistering on the ear drum. Exostosis is an overgrowth of the EAC bony canal, often found in cold water surfers. Sclerosis are white patches in the eardrum from prior infections or ear tubes.

Key Learning Points:

  1. Shagrination describes a speckled or cobblestoned appearance of the TM
  2. Shagrination likely results from the decompression of a bulging TM and may represent a resolving infection

Here is a video of the exam with the tick present.

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