Name That Ear Finding!

An 8 year-old patient presents with a few days of low-grade fever and left ear pain. On otoscopic exam, you see the tympanic membrane pictured below. What is this finding?

Bullous myringitis (BM) is the development of a vesicle/bulla on the tympanic membrane. Lesions can vary in size and number, and may cause severe pain. 

BM most often occurs in the presence of an underlying acute otitis media (AOM), but occurs in <10% of AOM cases overall. Treatment of BM involves pain control and standard treatment for AOM. 

A potential complication of BM is hearing loss (typically mixed), which is most often transient and improves with AOM treatment; however, there are reports of persistent hearing loss. As such, patients should undergo early audiometric evaluation. Systemic corticosteroids are often prescribed for hearing loss but definitive evidence supporting their use is lacking.

Other notes: 

  • Bullae involving the tympanic membrane should be distinguished from bullae involving only the ear canal; the latter suggests an alternative diagnosis, most often acute otitis externa. 
  • For unclear reasons, BM has traditionally been attributed to Mycoplasma pneumoniae infection, but this association appears to be a myth. Viral and bacterial pathogen distribution in AOM with BM is similar to that in AOM without BM. 
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