Bulging Assessment

A five-year-old male child presents to the emergency department (ED) with ear pain and fever. His mother explains that the child’s symptoms started with a runny nose about 4 days ago. He then developed a cough and congestion. About a day ago, the child complained of ear pain and fever to 102.1 F. The mother has been treating with fluids, acetaminophen, and ibuprofen. Treatment transiently helps with the symptoms and provides comfort. The child’s older siblings had viral symptoms that resolved about a week ago. The child continues to eat and drink, but with less enthusiasm. A chest x-ray does not show pneumonia, and a rapid strep test comes back negative. This image of the child’s ear is obtained.

Which of the following best describes this child’s tympanic membrane (TM) findings?

A. No bulging
B. Mild bulging
C. Moderate bulging
D. Severe bulging

This child’s TM is bulging. Assessing the degree of bulging is somewhat objective and often dichotomized into mild versus moderate/severe. This author feels the degree of bulging in this child’s TM is best described as moderate given the complete loss of bony landmarks but has not progressed fully to the classic “angry donut” appearance of more severe bulging. However, in this case, credit can be given for both moderate and severe—making the diagnosis of acute otitis media highly certain!

WiscMed has created a guide to acute otitis media that may be found here.