Bullous Myringitis vs Cholesteatoma Pearls
A 12-year-old male presents to the pediatric clinic for a well-child exam. The child and his parents have no concerns. He has no history of ear infections. The following image of his left ear is obtained. What is the diagnosis and treatment?
It appears to be asymptomatic bullous myringitis. It could also represent cholesteatoma pearls. Close follow-up is recommended.
This is an interesting case. An asymptomatic pediatric patient is here for a well-child visit with incidental discovery of apparent bullous myringitis (BM). BM may be considered to be on the “severe end” of acute otitis media (AOM). That is, AOM with additional features of infection. AOM generally presents with ear pain, decreased hearing, and signs of infection as seen in this image, that is; loss of bony landmarks, erythema (redness) along with bulging of the tympanic membrane (ear drum). The feature that separates BM from AOM is blistering. The diagnosis of BM is not definitive given the lack of symptoms experienced by the patient.
The other possibility is that the blisters actually represent cholesteatoma pearls. A cholesteatoma is an overgrowth of the epithelium of the tympanic membrane. The overgrowth can become a problem if it interferes with the proper functioning of the tympanic membrane or the middle-ear ossicles (bones).
It would a coincidence to have clear evidence of asymptomatic AOM (bulging of the ear drum) with incidental discovery of cholesteatoma pearls. For this reason, asymptomatic BM is the likely diagnosis. The child should return for re-evaluation in 1-2 weeks and if unchanged, be referred to ENT for evaluation of cholesteatoma. Given the lack of symptoms (pain, fever, decreased hearing), antibiotics are not indicated at this time.
WiscMed thanks Dr. Daniel Lapidius of Pediatric Affiliates for this interesting case. WiscMed also thanks Dr. Michael Poole of Georgia Ear, Nose, and Throat for his consult on this case. WiscMed highly recommends Dr. Poole’s book “Otitis: The Expert’s Diagnostic Guide.” Currently available at no cost on Apple Books.
Here is the complete video exam:
Complete exam video