Bullous Myringitis: A Case-Control Study

Prior studies have shown that bullous myringitis (BM) accounts for <10% of acute otitis media (AOM) cases, and that the distribution of viral and bacterial pathogens in BM is similar to that in AOM without BM, except for a relative increase in the proportion of Streptococcus pneumoniae in BM. We studied 518 cases of AOM in children aged 6 months to 12 years. Using tele-otoscopy to assist the diagnosis, we identified 41 cases (7.9%) with BM. Children who had AOM with BM were older than AOM patients without BM (median age: 4.3 years vs 18 months). We compared 41 cases of AOM with BM to 41 control cases of age-, race-, and gender-matched AOM patients without BM. When compared with this matched control group, children with BM had more severe symptoms at the time of diagnosis and were more likely to have bulging of the tympanic membrane in the quadrants that were not obscured by the bulla. Children with AOM and BM may require aggressive pain management. Although parents and clinicians may agree that a watchful waiting approach is appropriate for older children with mild AOM, children experiencing painful AOM with BM may not be successful candidates for a watchful-waiting approach, because parents may resist postponement of antibiotic therapy in children who are more symptomatic.