Image 1 Image 2
This child’s Wispr examination demonstrates a darkened, bulging TM consistent with hemotympanum (blood behind the ear drum), Image 1. In the setting of head trauma, hemotympanum typically occurs as a result of a basilar (lower) skull fracture with subsequent bleeding into the middle ear space.
Hemotympanum is often the earliest sign of basilar injury. Other later physical exam findings may include “racoon eyes,” and bruising behind the ear. Despite the child’s well-appearance (she was deemed PECARN negative), the finding of hemotympanum led the clinicians to pursue neuro-imaging that revealed a minimally displaced temporal bone fracture. The patient was admitted to the pediatric neurosurgery service for observation and recovered uneventfully from her injury without intervention.
Interestingly in this case, the initial evaluation was performed by standard otoscopy and reported as “a little dark in the canal, but otherwise normal”—a fact that demonstrates the challenge of viewing a non-perforated hemotympanum with a traditional otoscope. Light does not reflect strongly off the darkened TM which, combined with small canal diameter and the brief view so common in pediatrics, results in an incomplete assessment of the TM. Furthermore, just as with otitis media, not all hemotympanum appear the same (see Image 2 from a 10 year-old child who fell from a barn loft and sustained a complicated basilar skull fracture). In both cases, the WiscMed Wispr achieved diagnostic images that assisted clinicians with the correct neurologic workup, diagnosis and treatment.
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