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982 Full PDF
982 Full PDF
‘‘In Medicine one must pay attention not to plausible theorizing but to experience and reason together. . . . I
agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its
deductions from what is observed. . . . But conclusions drawn from unaided reason can hardly be serviceable;
only those drawn from observed fact.’’ Hippocrates: Precepts. (Short communications of factual material are
published here. Comments and criticisms appear as letters to the Editor.)
Bullous Myringitis: A Case-Control onto portions of the external auditory canal immedi-
ately adjacent to the TM.3 Bullae involving the TM
Study should be distinguished from bullae involving only
the ear canal; the latter are a form of external otitis
ABSTRACT. Prior studies have shown that bullous media (OM). It was once thought that Mycoplasma
myringitis (BM) accounts for <10% of acute otitis media
(AOM) cases, and that the distribution of viral and bac- pneumoniae infection was an important cause of
terial pathogens in BM is similar to that in AOM without BM,7–10 but this idea was later invalidated.11–13 In an
BM, except for a relative increase in the proportion of extensive review of the literature, Merrifield11 iden-
Streptococcus pneumoniae in BM. We studied 518 cases of tified reports of 612 patients with documented M
AOM in children aged 6 months to 12 years. Using tele- pneumoniae infection, and among these 37 patients
otoscopy to assist the diagnosis, we identified 41 cases had ear involvement (6 with BM). In reported cases
(7.9%) with BM. Children who had AOM with BM were of BM, 1 of 16 grew M pneumoniae. Of 858 attempts to
older than AOM patients without BM (median age: 4.3 isolate M pneumoniae from non-BM cases of AOM,
years vs 18 months). We compared 41 cases of AOM with
none grew M pneumoniae from the middle ear fluid.
BM to 41 control cases of age-, race-, and gender-matched
AOM patients without BM. When compared with this Merrifield concluded that: “The tympanic mem-
matched control group, children with BM had more se- brane’s ability to form blisters appears to be a non-
vere symptoms at the time of diagnosis and were more specific reaction. Bullous myringitis is merely acute
likely to have bulging of the tympanic membrane in the otitis media with blisters within the layers of the
quadrants that were not obscured by the bulla. Children eardrum. There is little evidence that otitis media,
with AOM and BM may require aggressive pain manage- with or without bullous myringitis, is caused by
ment. Although parents and clinicians may agree that a Mycoplasma pneumoniae.”
watchful waiting approach is appropriate for older chil- Studies have shown that BM accounts for ⬍10% of
dren with mild AOM, children experiencing painful
AOM cases, and that viral and bacterial pathogen
AOM with BM may not be successful candidates for a
watchful-waiting approach, because parents may resist distribution in BM is similar to that in AOM without
postponement of antibiotic therapy in children who are BM, except for a relative increase in the proportion of
more symptomatic. Pediatrics 2003;112:982–986; acute oti- Streptococcus pneumoniae in ears with bullae.14,15 Al-
tis media, diagnosis, bullous myringitis, case-control, though descriptive studies indicate that BM is a se-
child. vere form of AOM, no quantitative information on
the clinical severity of illness has been reported in
ABBREVIATIONS. BM, bullous myringitis; TM, tympanic mem- AOM patients with and without BM. In this case-
brane; AOM, acute otitis media; OM, otitis media; OM-3, otitis control study, we compared the clinical severity of
media 3-item questionnaire: UTMB, University of Texas Medical AOM with or without BM, based on parent’s percep-
Branch at Galveston; OS-8; otoscopy score, 8 grades. tion of illness, body temperature, tympanogram, and
otoscopic findings.
B
ullous myringitis (BM) is an acutely painful
condition of the ear characterized by bulla for- METHODS
mation on the tympanic membrane (TM). BM
was described in early articles as occurring in asso- Subjects
ciation with acute otitis media (AOM).1,2 Previous We prospectively recruited a convenience sample of children
with symptomatic AOM (aged 6 months to 12 years) from our
studies indicated that BM is often associated with pediatric clinic. Patients were initially identified if they had signs
fever3 and considerable pain,3,4 possibly because the and symptoms of AOM as described below. Patient enrollment
blisters of BM may occur between the richly inner- occurred between May 2000 and August 2002. Verbal assent was
vated outer epithelium and middle fibrous layers of obtained from parents as approved by our institutional review
the TM.5,6 Bullae involving the TM may also extend board. Oral, rectal, or axillary body temperatures were measured
by electronic thermometer. All oral and rectal temperatures were
corrected to axillary (skin) temperature for the purpose of com-
Received for publication Dec 13, 2003; accepted Jun 3, 2003. parability. Parents completed a demographic questionnaire on
Davis C. Teichgraeber, BA, is a third-year medical student at the University risk factors such as duration of breastfeeding (months), day care
of Texas Medical Branch at Galveston, Galveston, Texas. attendance (not attending, 1–20 hours/week, 21– 40 hours/week,
Reprint requests to (D.P.M.) Department of Pediatrics, Primary Care Pavil- ⬎40 hours/week), passive tobacco smoke exposure at home (not
ion, 400 Harborside Dr, Rm 2.701, Galveston, TX 77555-1119. E-mail: exposed or exposed), and prior history of ear infections (number
david.mccormick@utmb.edu of infections). To be included in the study, children were required
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- to have 1) symptoms, 2) evidence of acute inflammation of the TM,
emy of Pediatrics. and 3) middle-ear effusion.
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