Toddler with URI

A 4-year-old child is brought to the emergency department (ED) for evaluation of a bloody nose (epistaxis). His parents note he gets them frequently, but this one did not stop with pressure “like it usually does.” The child has been congested for several days but has not had a fever and denies ear pain. His exam demonstrated a small amount of dried blood crusting the right anterior nasal septum. The child’s Wispr exam of his right ear is shown. The remainder of his exam is unremarkable.

What is the appropriate evaluation and management for this child’s condition?

A. He has a middle ear effusion.
B. He has severe bulging of the TM and should be offered immediate treatment with antibiotics.
C. The child has hemotympanum, from retrograde nose blood via the Eustachian tube.
D. A & B

This child has a cloudy middle ear effusion (MEE), an incidental finding to the presenting concern of a nosebleed. The initial inclination may be to start treatment for acute otitis media (AOM). However, it is important to not only determine if the findings are sufficient to diagnose AOM, but also if the symptoms are severe enough to warrant immediate treatment with antibiotics.

Research strongly supports using tympanic membrane (TM) bulging as a sensitive indicator of AOM (Seeing is Believing 1). However, since bulging occurs on a continuum, clinicians must be adept at identifying mild bulging from moderate/severe bulging in order to make a confident diagnosis. The superiorly located pars flaccida is the most compliant portion of the TM and therefore is typically the first area to bulge when pressure increases in the middle ear space. With this early bulging, clear visualization of the bony malleus is impaired and the TM appears “full” with a slight umbo dimple located centrally. As bulging progresses, the central dimple becomes deeper and the malleus more difficult to visualize. With moderate to severe bulging, the deepening dimple results in the appearance of an “angry donut.”

This child’s TM does not demonstrate the donut sign, however, the malleus is not clearly visualized and there is a slight central depression—consistent with mild bulging of the pars flaccida. While mild bulging may be a sign of early AOM, it is also observed with fever, crying, and resolving AOM. Therefore, additional signs or symptoms—either recent onset of ear pain or intense erythema--must be present to diagnose AOM confidently (Seeing is Believing 2). While there is some injection of the TM, it is not enough to make a definitive diagnosis of AOM and begin immediately initiating antibiotics. Additional findings reassuring against AOM  are the presence of air in the middle airspace (indicating the Eustachian tube is patent) and a translucent TM with a normal light reflex (i.e. cone of light in the anterior inferior quadrant), suggesting the membrane itself is not inflamed.  All of these findings--a MEE without evidence of significant inflammation indicate this child most likely has otitis media with effusion (OME) and does not require antibiotics.  

There is no evidence of blood behind the ear drum (hemotympanum), although retrograde delivery of blood to the middle ear space from a nosebleed does occur as shown in this case.

WiscMed has published a handy acute otitis media treatment poster based on American Academy of Pediatric (AAP) guidelines that may be found here. 

Complete video of the exam

Key Learning Points: 

1. AOM is characterized by the presence of a MEE with signs of inflammation.
2. Bulging of the TM is the most important indicator of AOM.
3. While moderate/severe bulging is sufficient to make a confident diagnosis of AOM, mild bulging requires additional findings including fever and pain.
4. OME is characterized by the presence of a MEE without inflammation.

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