A 6-year-old female presents to the pediatric clinic with ear pain. She has a history of acute otitis media (AOM), but no history of ventilation tubes. She has had the pain for about 6 days. The ear pain was preceded by viral symptoms including cough, congestion, and a sore throat. The parents have been treating the child with over-the-counter analgesics. They brought the child in because the ear pain does not seem to be getting better. On exam, the child appears well, although uncomfortable from the ear pain. Vital signs are normal and she is afebrile. The ear exam is shown. What action should be taken?
The child has acute otitis media with evidence of shagrination (cobble stoning). Antibiotics should be considered in consultation with the parents.
Acute otitis media (AOM) is diagnosed by the bulging tympanic membrane (TM, eardrum). The bulging represents pressure in the middle ear space due to fluid from inflammation. The presence of the fluid indicates that the Eustachian tube is not properly draining the middle ear space to the posterior nasopharynx. The bulging looks painful, and it is. The appearance is often described as an “angry donut” or “angry bagel.” This appearance is because the most distal part of the malleus, the umbo, creates the central dimple when the TM is under pressure. Compare this case to that of a normal eardrum.
In addition to features of AOM, the eardrum also appears to have shagrination1 (cobble stoning). Shagrination can be thought of as “stretch marks” on the eardrum and may be associated with improvement in the middle ear pressure. In other words, the stretch marks start to appear as the bulging subsides. This could indicate that the infection is resolving.
The choice of treatment, in this case, requires a discussion between the physician and the parents. Given the presence of shagrination, it would not be unreasonable to defer antibiotics and give careful return instructions. However, given the child has had symptoms for almost a week, it is most likely that the parents would prefer immediate treatment.