Day: April 8, 2013

How Common Is Bullous Myringitis?

Patient Presentation
A 2-year-old female came to clinic after 16 hours of severe right ear pain. She had fever to 38.5° and was being given ibuprofen. Previously she had rhinorrhea for 3 days but no cough. The past medical history showed an episode of otitis media 7 months previously. The review of systems was otherwise negative. The pertinent physical exam showed a cranky female with normal vital signs and growth parameters in the 90-95% for age. HEENT revealed moderate rhinorrhea, normal pharynx and eyes. Her left tympanic membrane was erythematous with mild bulging, distorted landmarks and immobility. Her right tympanic membrane was very erythematous with an orange hue, and was dramatically bulging with 3 blisters on the lower 1/2 of the membrane. The rest of her examination was negative. The diagnosis of bullous myringitis was made and amoxicillin-clavalaunic acid was given. The parents were told to use acetaminophen or ibuprofen for pain relief and told that because the blisters were relatively friable there was a chance that one could break and the child would have otorrhea. The patient was to follow-up in about 4 weeks to recheck the ear.

Discussion
Bullous myringitis (BM) is felt to be a variation of acute otitis media (AOM) with more severe symptoms. Bullae (blisters or “balloons”) on the tympanic membrane occur between the outer epithelial layer and middle fibrous layers of the tympanic membrane. The exact reason for this is unknown but felt to be probably due to a strong inflammatory reaction in the middle ear begun by viral or bacterial pathogens. The pain is felt to be due to irritation of the highly innervated outer epithelial layer. The most common pathogens are the same as AOM but Streptococcus pneumoniae is detected more often. The bullae can occur on the tympanic membrane but also extend to the proximal aspect of the external ear canal (in about 10% of BM cases). Bullae that only involve the external canal are due to otitis externa and should be distinguished from BM. Symptoms that are present more often in patients with BM than AOM include severe earache and fever, but also ear rubbing, poor sleep, more crying and decreased appetite.

While most cases are due to infectious diseases, one case in the literature reported BM due to organic solvent (paint thinner) entering the nasal cavity and into the middle ear with what appeared to be direct cellular damage to the structures.

The American Academy of Pediatrics recently updated their clinical practice guidelines for the treatment of acute otitis media in children. See To Learn More below.

Learning Point
Overall, BM is felt to occur in < 10% of patients with AOM. One prospective longitudinal cohort study found of 2028 children followed from 2-24 months, they had 1876 visits for AOM (1876/2028 = 92.5%) in 2683 ears. Eighty-six visits were for BM (86/1876 = 4.6%) in 92 ears. Bullae spread from the tympanic membrane to the external canal in 9 ears (9/92 = 9.8%).

Questions for Further Discussion
1. What is the difference between pneumatic otoscopy and tympanometry? How do they help to determine if AOM is present?
2. What other treatment(s) besides antibiotics can be offered for BM?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

McCormick DP, Saeed KA, Pittman C, Baldwin CD, Friedman N, Teichgraeber DC, Chonmaitree T. Bullous myringitis: a case-control study. Pediatrics. 2003 Oct;112(4):982-6.

Minoda R, Miwa T, Sanuki T, Yumoto E. An unusual cause of bullous myringitis with acute otitis media. Otolaryngol Head Neck Surg. 2011 Nov;145(5):874-5.

Kotikoski MJ, Palmu AA, Puhakka HJ. The symptoms and clinical course of acute bullous myringitis in children less than two years of age. Int J Pediatr Otorhinolaryngol. 2003 Feb;67(2):165-72.

Liberthal AS, Carroll AE, Chonmaitree T et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013. Available from the Internet at: http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.abstract (rev. 2/25/13, cited 2/25/13).

ACGME Competencies Highlighted by Case

  • Patient Care
    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.

  • Medical Knowledge
    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.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital