Resolving Acute Otitis Media (AOM) – December 5, 2024
A 3-year-old female presented to the emergency department (ED) with complaints of cough, congestion, and low-grade fever for the previous two days. The child had not been fussy and her mother reports normal activity level. She was afebrile and overall well-appearing with clear nasal discharge. Her Wispr digital otoscopic exam is attached below.
Which of the following is true about her condition?
- She has evidence of early acute otitis media (AOM) and should be provided a just-in-case prescription for antibiotics.
- She has acute otitis media (AOM) and should be treated immediately with antibiotics.
- She has evidence of a resolving otitis media and does not require antibiotics.
- She requires an urgent consult to otolaryngology (ENT) to place ventilation (ear) tubes.
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:
- Mucupurulent patches adhere to the internal (middle ear) surface of the TM.
- 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.
- Small blood vessels may be visible around and within the patches and likely indicate a later phase of resolution.
Here is the complete video exam.
