Myringosclerosis – August 24, 2023
A 4-year-old child presents to the emergency department (ED) for evaluation of cough, congestion, and fever for one day. Due to a prior history of “many ear infections,” the parents wished to have his ears checked prior to leaving for a vacation the following day. The family will be flying out of the country and medical care might not be easily obtained. Upon further questioning, the parents express some concern about their child’s speech development and state their regular physician has mentioned hearing tests. In the ED, the child is afebrile and well-appearing with mild rhinorrhea but no other focal respiratory findings. His Wispr digital otoscope exam is shown.
Which of the following is the most appropriate plan:
- Antibiotics should be prescribed.
- Urgent referral to otolaryngology (ENT).
- Recommend use of a nasal corticosteroid prior to boarding the plane for their trip.
- Recommend follow-up with their primary physician upon returning home.
Answer: D. Recommend follow-up with their primary physician upon returning home.
This child has an impressive amount of myringosclerosis. Myringosclerosis appears as white patches on the tympanic membrane (TM) and results from calcium deposition following repeated episodes of acute inflammation, persistent middle ear fluid, trauma, or tympanostomy tube placement. Despite its appearance, myringosclerosis usually does not impact hearing as long as there is no involvement of the middle ear structures (in which case the term tympanosclerosis is used). It is important to recognize that conditions leading to myringosclerosis (ie persistent fluid or frequent acute infections) can independently contribute to a conductive hearing deficit and may manifest as speech delay. Therefore, children with myringosclerosis and concern for hearing or speech should be followed closely with appropriate ENT referral and audiology testing.
This child’s Wispr exam does not show signs of acute infection—there is no bulging or intense erythema—so antibiotics are not indicated for either acute treatment or expectant management. The child has an upper respiratory illness, so presence of a middle ear effusion (MEE) and Eustachian tube dysfunction are possibilities. However, the degree of myringosclerosis obscuring the normal translucency of the tympanic membrane (TM) makes it difficult to visualize if there are tell-tale air-fluid levels or bubbles behind the TM to suggest otitis media with effusion (OME). Regardless, while there may be some role for newer generation nasal corticosteroids in children with OME and URI symptoms, initiating prior to boarding the plane would likely be of little benefit to the child.
WiscMed has created a visual diagnosis guide to common ear conditions that may be found here.
Pelton, S.I., Marom T. Otitis Media with Effusion (Serous Otitis Media) in Children: Clinical Features and Diagnosis. UpToDate. Retrieved Aug 20, 2023 from uptodate.com
Roditi, R.E., Caradonna, D.S. & Shin, J.J. The Proposed Usage of Intranasal Steroids and Antihistamines for Otitis Media with Effusion. Curr Allergy Asthma Rep 19, 47 (2019)