A 5-year-old male came to clinic after waking up in the morning crying in pain that his right ear hurt. He had been having thick, yellow rhinorrhea for the past 5 days but was otherwise well.
His mother gave him Ibuprofen and a warm pack to place on his ear but it took almost two hours before the pain was under control.
The past medical history showed him to have 3 episodes of otitis medias in the past.
The pertinent physical exam showed a healthy appearing male in some discomfort who was afebrile and had growth parameters in the 10-50%.
His right ear was very reddened, bulging, with distorted landmarks and a distinct bullae at the 3-5 o’clock position. There appeared to be yellow pus behind the tympanic membrane.
He had mild, thick yellow rhinorrhea and some shoddy anterior cervical lymph nodes bilaterally. The rest of his examination was normal.
The diagnosis of right bullous myringitis with acute otitis media was made. He was begun on Amoxicillin and the physician reviewed the appropriate dosing for analgesics.
He also told the mother that the bulla could perforate and if this occurred to telephone so that eardrops could be prescribed.
About 12 hours after he had awoken crying, the patient’s clinical course evolved and he complained of wetness in his ear to his mother. She saw a sticky, yellow film on the ear and wet discharge.
The mother telephoned the physician and during the conversation inquired about how long he couldn’t swim because of the water getting into his ear.
The physician told the mother that usually the hole heals up in 1-2 days and that he should not swim until the otorrhea was gone and then 1 day more for good measure. He recommended at least 3 days. He also said to place a small piece of cotton into the patient’s ear during bathing to protect the ear.
The physician also prescribed Ciprodex® otic drops to be used twice a day until at least 1 day after the otorrhea was completely gone. He told the mother to have the child be seen in 4-6 weeks to make sure there was resolution of the otitis media particularly since there was a perforation.
Otitis media is one of the most common conditions affecting children.
Thomas Rotch, the famous pediatrician, in his first edition of Pediatrics from 1896 quotes several contemporary studies which showed evidence of middle ear disease in 30-80% of infants.
Rotch quotes Anton Von Tröltsch who first described otosclerosis in 1864, saying “there is an unusually strong disposition to disease of the middle ear, owning on the one hand to the double influence of the peculiar morphological relations of the ear and the pharynx, and on the other hand to the disease and condition of life to which the child is frequently exposed.”
Rotch then states himself, “We should therefore consider carefully the ear in all cases where the symptoms are obscure, as well as where those diseases are present in which it is well know that aural complications are liable to arise.”
Today, over 30 million prescriptions are written yearly for otitis media and they account for 40% of all prescriptions for children < 10 years of age.
Over 1 million sets of tympanostomy tubes are placed yearly. By the age of 4, 2-6% of children will have at least one set of tympanostomy tubes.
Otitis media is categorized into 3 entities:
- Acute otitis media – purulent middle ear effusion with systemic symptoms of usually fever and otalgia
- Otitis media with effusion – middle ear effusion without acute or systemic symptoms
- Chronic supprative otitis media – recurrent foul-smelling otorrhea which may be associated with perforations and cholesteatoma
Myringitis is inflammation of the tympanic membrane. It may be primary (a self-maintained disease, e.g. direct trauma from a foreign body, barotrauma) or secondary (associated with processes adjacent to the tympanic membrane such as acute otitis media).
Acute bullous myringitis is often caused by Streptococcus pneumoniae or viral infections (e.g. influenza, herpes zoster).
Tympanic membranes that perforate usually heal up in 12-48 hours after spontaneous rupture.
Sometimes permanent perforation may occur. These can be symptomatic or assymptomic (except for a conductive hearing loss).
In addition to the conductive hearing loss, permanent perforation has other potential complications including cholesteatoma, ossicular discontinuity, and repeated infections with their own complications such as sensorineural hearing loss, extension into the bones of the skull (e.g. mastoiditis) or into the skull cavity itself (e.g. meningitis).
Referral to an otolaryngolist should be made if there is any concern for a permanent perforation or any potential complication.
Questions for Further Discussion
1. What complications are caused by cholesteatomas?
2. What causes of performation of the tympanic membrane?
3. What causes ear pain that is not caused by aural structures?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Rotch TM. Pediatrics. 1st Edition. J.B. Lippincott and Co. Philadelphia, PA. 1895;1106.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1249-1255.
Uliyanov YP, Schweinfurth, J. Middle Ear, Tympanic Membrane Infections. eMedicine.
Available from the Internet at http://www.emedicine.com/ent/topics205.htm (rev. 10/3/2006, cited 8/9/2007).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
October 1, 2007