This Ear Looks Different

Patient Presentation
A 15-month-old male came to clinic with a 2 day history of rhinorrhea, fever to 101.7° F, and fussiness especially at night. His mother was unable to console him the previous night and both looked very tired. He had no cough oreye changes and was drinking but not eating very much. The past medical history showed 2 ear infections in the past. The most recent was 3 months ago. The pertinent physical exam revealed a tired male who was afebrile with normal vital signs and growth parameters between 25-50%. He was well-hydrated. There was mild clear rhinorrhea and normal pharynx. His right ear had a bulging, erythematous tympanic membrane without light reflex. The left tympanic membrane was erythematous without normal landmarks but also had some centripetally radiating lines from the malleus. The tympanic membrane appeared to have a material similar to adherent scale attached to the membrane in between these lines.

The diagnosis of bilateral otitis media was made and the patient was started on antibiotics. The resident who was seeing the patient said she had never seen a tympanic membrane with these types of changes. The attending physician said that she had and it was a variant of acute otitis media but wasn’t sure exactly what the name was for it. The following day the attending found a picture and papers with descriptions of the normal keratinization of the tympanic membrane and normal healing process of tympanic membrane. The attending still wasn’t sure what to call these specific keratin changes but understood how they occurred.

The tympanic membrane has two parts, the pars flaccida and the pars tensa. Each has 3 major layers: an external keratinizing squamous epithelial layer, a central connective tissue layer, and an internal epithelial layer. The pars flaccida connective tissue layer is less well-organized than the pars tensa.

Learning Point
Normally, there is a centripetal migration of the keratinocytes from the central part of the tympanic membrane (along the malleus) outward to the periphery. An india ink stain of this process can be seen here. The cell migration outward is slow to begin with (i.e. new cells stay near the central area for several weeks) then as they move toward the periphery the migration speed increases. This can easily be seen in keratin patch formation. Keratin layers split during the migration forming patches similar to ice flows or the well-demarcated spots on a giraffe. An image can be seen here.

Tympanic membrane perforations also appear to heal in a similar way, by the movement of keratinocytes from the malleus area to the periphery as one of the initial activities. Repair of the other layers seems to follow for the tympanic membrane. Most acute perforations heal spontaneously, but others may not causing chronic perforations which are associated with ear discharge, recurrent infections, conductive hearing loss, speech and language delays and cholesteatomas. Chronic supprative otitis media is also increased with chronic perforations and is associated with other intra- and extra-cranial morbidities such as meningitis and abscess. Spontaneous healing is less likely depending on the etiology (i.e. trauma vs spontaneous), large perforation size, presence of ear drainage, pre-existing tympanosclerosis and if wrong interventions are used such as ear syringing.

Questions for Further Discussion
1. What causes bullous myringitis?
2. What are the indications for consultation with an otolaryngologist for tympanic membrane perforation?

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, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Ear Infections and Ear Disorders.

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos. Tympanic membrane surface migration. Available from the Internet at (rev. 11/30/1999, cited 4/15/2014). Tympanic membrane keratin patches. Available from the Internet at (rev. 11/30/1999, cited 4/15/2014). Tympanic membrane formation of keratin patches. Available from the Internet at (rev. 11/30/1999, cited 4/15/2014).

Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforation of the tympanic membrane. Clin Otolaryngol. 2008:33;420-6.

Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. Histology of the healing tympanic membrane following perforation in rats. Laryngoscope. 2010 Oct;120(10):2061-70.

Lou ZC, Tang YM, Yang J. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin Otolaryngol. 2011:36;450-60.

Lou Z. Late crust formation as a predictor of healing of traumatic, dry and minor-sized tympanic membrane perforations. J. Otolaryngology. 2013:34;282-386.

Mei Teh B, Redmond SL, Shen Y, Atlas MD, Marano RJ, Dilley RJ. TGF-alpha/HA complex promotes tympanic membrane keratinocyte migration and proliferation via ErbB1 receptor. Exp Cell Res. 2013 Apr 1;319(6):790-9.

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.

  • 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.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.


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