A 6-year-old female presents to the pediatric clinic with her mother. The child has had 3 days of viral symptoms including cough, congestion, and fever. She does not have any ear complaints. As part of the physical exam, this image of her right ear was obtained.
What is your diagnosis, and what intervention is indicated?
The child has mild bulging of her eardrum. Treatment with antibiotics might or might not be indicated. She likely has a viral infection causing her primary symptoms.
This is a common clinical situation. A child with viral symptoms and an ear exam that is equivocal for acute otitis media (AOM). There is clearly mild bulging of the eardrum, particularly the pars flaccida portion. However, the pars tensa portion is only mildly bulging. There is a slight dimple present at the umbo of the malleus. The short process of the malleus is still discernable. Here are examples of mild, moderate, and severe bulging. As the severity of the bulging increases, it becomes more difficult to discern the malleus ossicle.
Mild bulging of the tympanic membrane
Moderate bulging of the tympanic membrane
Severe bulging of the tympanic membrane
This article on Wispr University discusses the significance of bulging in the diagnosis of AOM. In the case of mild bulging, as seen in this case, secondary factors such as the presence of pain may help the practitioner to make the decision regarding treatment with antibiotics. Given that this patient had no pain, it would be reasonable to defer antibiotics while providing the family with careful return instructions.