Shagrination

A 23-month-old presented to the emergency department (ED) with a chief complaint of fever. Her parents reported that their child had a runny nose and mild cough for two days. Last night she seemed uncomfortable and tearful, which her parents noted was unusual. She spiked a fever of 102.5^o F that morning,  In the ED, the child was febrile to 104^o F but otherwise had appropriate vital signs. She appeared tired but non-toxic. Her HEENT exam demonstrated yellow rhinorrhea, a clear oropharynx, and no lymphadenopathy. Her Wispr digital otoscope exam is shown.

Which of the following best describes the child’s Wispr findings?

A. Moderate to severe bulging
B. Cobble stoning
C. Bullous myringitis 
D. A & B

This child has acute otitis media (AOM) with her tympanic membrane (TM) demonstrating cobble stoning, also known as shagrination. Her TM is moderately bulging as evidenced by the “donut sign.” Note the deep depression centrally where the umbo anchors to the TM and resists the bulging pressure in the middle ear. Case reports suggest that cobble stoning indicates bulging has peaked and that the middle ear space is now decompressing. While it is possible the infection might continue to resolve without antibiotics, given her age, discomfort, moderate bulging, and new fever (viral swabs were negative in the ED), the patient was initiated on a course of amoxicillin.

WiscMed has an image series of resolving AOM which demonstrates the development of shagrination that can be found here.

Key Learning Points

1. Shagrination describes the cobble-stoned texture of the tympanic membrane (TM).
2. Case reports suggest that shagrination occurs as the TM decompresses from its peak bulging, like a deflating balloon.
3. Future studies are necessary to determine if antibiotics can be deferred when shagrination is present.

Armengol CE, Hendley JO. Shagrination during acute otitis media. J Pediatr. 2014 Oct;165(4):870-870.e1. doi: 10.1016/j.jpeds.2014.06.002. Epub 2014 Jul 16. PMID: 25039040.