Bullous Myringitis – February 22, 2024

Bullous Myringitis – February 22, 2024

A 7-year-old presented to the emergency department (ED) with severe left ear pain. The pain woke her from sleep and did not respond to a dose of Tylenol, so the child’s mother brought her in for evaluation. She reports her daughter has had congestion but no fever for the past several days. She is otherwise generally healthy with up-to-date immunizations and has no known drug allergies. The physical exam is remarkable for an uncomfortable, crying child. Her Wispr digital otoscope exam is shown.

Which of the following have been implicated in the child’s condition?

  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Group A Streptococcus
  4. Respiratory Syncytial Virus (RSV)
  5. All of the above

Answer: E. All of the above

The child has bullous myringitis as evidenced by the impressive blister on her tympanic membrane (TM, ‘eardrum’). Bullous myringitis (BM) is often thought of as a “severe” form of acute otitis media (AOM). BM has bulging and blistering while AOM has bulging without blistering.  While an early investigation suggested mycoplasma pneumonia as the most common pathogen, further studies have demonstrated Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Group A Streptococcus, and Staphylococcus aureus (i.e. the “typical” AOM bacteria) are all frequently isolated when pathology is conducted. In addition, as with many infectious diseases in young children, coinfections with respiratory viruses such as RSV and influenza are common. In a child with no drug allergies and no recent treatment with antibiotics, the American Academy of Pediatrics’ AOM guideline recommends high-dose amoxicillin as the first-line choice for therapy.  Bullous myringitis looks painful, and it is.  Pain control with oral ibuprofen or Tylenol and topical anesthetic such as proparacaine is important given the severity of ear pain in children with bullous myringitis.

Devaraja K. Myringitis: An update. J Otol. 2019 Mar;14(1):26-29.

Lieberthal et al. AAP Practice Guideline: The Diagnosis and Management of Acute Otitis MediaPediatrics (2013) 131 (3): e964–e999.

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