and the pediatricians are notorious for being
for all physicians,
because the children may not be able
to tell you that they have ear pain.
So ear pain and hearing loss,
at least transient hearing loss, are
fairly common in acute otitis media.
This is part of the challenge
of identifying babies who
have acute otitis media,
sometimes it’s very
difficult to examine them.
You definitely need a good assistant
to hold the patient still.
There’s always the danger of injuring their
external auditory canal with the otoscope.
A wiggling, screaming child
is difficult to evaluate
and the pediatricians are
notorious for being very patient
and it’s a very wonderful calling.
But what they’re looking for is
marked tympanic membrane erythema
and the eardrum can look
red when a child is
having forceful Valsalva maneuvers
such as when they’re crying.
They’re also looking for a
bulge in the tympanic membrane
where it seems to be coming
toward the observer.
That’s difficult to see.
Also, difficult to see is impaired
mobility of the tympanic membrane,
you really need a cooperative
patient to do that.
And normally, the eardrum is
supposed to be very mobile.
If it’s not mobile, there’s
probably fluid behind it.
Some of the nonspecific clinical features
that pediatricians think
about are ear pulling,
irritability, fever, decreased
appetite, and sleep disturbance.
So I think you can see why a
lot of kids get antibiotics
because the physician just can’t be sure
whether they have otitis media or not.
There’s a curious finding
called bullous myringitis.
And to describe it to you, it
would be a tympanic membrane
with a bleb on it, a bulla.
And when I was in training,
I was taught that that was pathognomonic
of Mycoplasma pneumoniae
But it turns out that it probably can be
caused by any of the common pathogens
and it’s not specific to
But the problem is just on the tympanic
membrane, there is a bleb on it.
It presently is just a manifestation
of severe acute otitis media,
and other bugs can do it.
So the normal tympanic
and it moves like a flapping flag,
it’s very sensitive to
the least movement.
Well, it has to be for hearing.
So when it doesn’t move,
there’s usually fluid behind it.
So it’s obvious that the clinical picture
is the way we make
In most instances, we are not going to be
using a needle to get
middle ear fluid.
That was done in days gone by,
but we don’t do myringotomies
anymore in most patients.
You would do a myringotomy and
get some middle ear fluid,
your ENT physician would
generally do that,
in somebody who had otitis
media and was critically ill,
and I think you can see
why we would need to know
what bug is making the
patient critically ill.
In an extremely toxic individual
with no response to antibiotics
within 48 to 72 hours,
we need to find
out what’s there.
And in an immunocompromised
patient, they can have funny bugs.
And I know of a patient that had actually
tuberculous otitis media that was missed
and missed and missed
again until finally,
one of the ENT physicians
did a biopsy of some tissue
around the middle ear and was
able to make the diagnosis.
So we need to think of strange organisms
in immunocompromised patients.