A four-year-old previously well male is brought into the emergency department at 2 am by his parents with concern for cough. The daycare attending child has had 3 days of cough, runny nose, and mild fever. The parents report that multiple children at daycare have been ill recently. The child continues to eat and drink, but with less enthusiasm than typical for him. They have been treating his symptoms with over-the-counter medications. On exam, the child appears ill without being toxic. He has a temperature of 38 C, appropriately resists the exam, and is crying robustly. He has copious tears and oral secretions. The following image of his right ear is obtained.

What are your diagnosis and treatment?

The child’s ear is erythematous (red), but there is no sign of infection. He likely has a viral infection.

An advantage of the Wispr digital otoscope is the ability to capture images and videos. This allows you to review the image on the device without the pressure of making a diagnosis while examining a squirming child. If a practitioner only had a brief glimpse of this ear, it is likely that the impression would be of marked erythema (redness) without also recognizing that there are no other signs of infection such as bulging or loss of bony landmarks. It’s possible that the child could be inappropriately started on antibiotics with only a brief glance. The Wispr otoscope gives time for thoughtful review of the exam. Because there is no sign of infection, antibiotics are not indicated.

Note that in this case there is no bulging of the tympanic membrane (TM, eardrum) and that the malleus bone is clearly visible. There are several irregularities of the TM of unknown origin that may be effusions although that is not supported by the appearance of the rest of the TM. Compare this case to acute otitis media (ear infection) and normal.

The cause of the erythema is most likely crying.