EXPERIENCE AND REASON—Briefly Recorded
‘‘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
Study
ABSTRACT. Prior studies have shown that bullous
myringitis (BM) accounts for <10% of acute otitis media
(AOM) cases, and that the distribution of viral and bac-
terial 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 se-
vere 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 manage-
ment. Although parents and clinicians may agree that a
watchful waiting approach is appropriate for older chil-
dren 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. Pediatrics 2003;112:982–986; acute oti-
tis media, diagnosis, bullous myringitis, case-control,
child.
ABBREVIATIONS. BM, bullous myringitis; TM, tympanic mem-
brane; AOM, acute otitis media; OM, otitis media; OM-3, otitis
media 3-item questionnaire: UTMB, University of Texas Medical
Branch at Galveston; OS-8; otoscopy score, 8 grades.
B
ullous myringitis (BM) is an acutely painful
condition of the ear characterized by bulla for-
mation on the tympanic membrane (TM). BM
was described in early articles as occurring in asso-
ciation with acute otitis media (AOM).1,2 Previous
studies indicated that BM is often associated with
fever3 and considerable pain,3,4 possibly because the
blisters of BM may occur between the richly inner-
vated outer epithelium and middle fibrous layers of
the TM.5,6 Bullae involving the TM may also extend
Received for publication Dec 13, 2003; accepted Jun 3, 2003.
Davis C. Teichgraeber, BA, is a third-year medical student at the University
of Texas Medical Branch at Galveston, Galveston, Texas.
Reprint requests to (D.P.M.) Department of Pediatrics, Primary Care Pavil-
ion, 400 Harborside Dr, Rm 2.701, Galveston, TX 77555-1119. E-mail:
david.mccormick@utmb.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
982 PEDIATRICS Vol. 112 No. 4 October 2003
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onto portions of the external auditory canal immedi-
ately adjacent to the TM.3 Bullae involving the TM
should be distinguished from bullae involving only
the ear canal; the latter are a form of external otitis
media (OM). It was once thought that Mycoplasma
pneumoniae infection was an important cause of
BM,7–10 but this idea was later invalidated.11–13 In an
extensive review of the literature, Merrifield11 iden-
tified reports of 612 patients with documented M
pneumoniae infection, and among these 37 patients
had ear involvement (6 with BM). In reported cases
of BM, 1 of 16 grew M pneumoniae. Of 858 attempts to
isolate M pneumoniae from non-BM cases of AOM,
none grew M pneumoniae from the middle ear fluid.
Merrifield concluded that: “The tympanic mem-
brane’s ability to form blisters appears to be a non-
specific reaction. Bullous myringitis is merely acute
otitis media with blisters within the layers of the
eardrum. There is little evidence that otitis media,
with or without bullous myringitis, is caused by
Mycoplasma pneumoniae.”
Studies have shown that BM accounts for ⬍10% of
AOM cases, and that viral and bacterial pathogen
distribution in BM is similar to that in AOM without
BM, except for a relative increase in the proportion of
Streptococcus pneumoniae in ears with bullae.14,15 Al-
though descriptive studies indicate that BM is a se-
vere form of AOM, no quantitative information on
the clinical severity of illness has been reported in
AOM patients with and without BM. In this case-
control study, we compared the clinical severity of
AOM with or without BM, based on parent’s percep-
tion of illness, body temperature, tympanogram, and
otoscopic findings.
METHODS
Subjects
We prospectively recruited a convenience sample of children
with symptomatic AOM (aged 6 months to 12 years) from our
pediatric clinic. Patients were initially identified if they had signs
and symptoms of AOM as described below. Patient enrollment
occurred between May 2000 and August 2002. Verbal assent was
obtained from parents as approved by our institutional review
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-
parability. Parents completed a demographic questionnaire on
risk factors such as duration of breastfeeding (months), day care
attendance (not attending, 1–20 hours/week, 21– 40 hours/week,
⬎40 hours/week), passive tobacco smoke exposure at home (not
exposed or exposed), and prior history of ear infections (number
of infections). To be included in the study, children were required
to have 1) symptoms, 2) evidence of acute inflammation of the TM,
and 3) middle-ear effusion.
Symptoms
All subjects had acute onset of symptoms, signs of TM inflam-
mation, and presence of middle-ear fluid.16 Because a valid and
standardized severity scoring method was not available for AOM,
we asked parents to report the severity of their child’s ear infection
symptoms on a questionnaire (OM-3) that listed the 3 acute illness
items from Rosenfeld’s OM health status questionnaire,17 origi-
nally designed for children with chronic middle-ear effusion. The
OM-3 questionnaire consisted of the following 3 items: “During
the past 24 hours, has your child experienced any of the following
attributable to ear infection a) physical suffering such as ear pain,
ear discomfort, high fever, or poor balance, b) emotional distress
such as irritability, frustration, sadness, restlessness, or poor ap-
petite, and c) limitation in activity such as playing, sleeping, doing
things with friends/family, attending school or day care.” Parents
indicated the severity of each of the 3 OM-3 items by marking a
7-point Likert scale from 1 (“not present, not a problem”) to 7
(“extreme problem”). The duration of time between the onset of
AOM symptoms and the diagnosis was not recorded in this study.
OM-3 total scores were calculated as the sum of the 3 items.
We validated OM-3 for use in children with AOM as follows: a)
6 UTMB (University of Texas Medical Branch at Galveston) expert
investigators agreed on its face validity, b) OM-3 demonstrated
inter-item reliability (␣ ⫽ 0.80; n ⫽ 518 children with AOM, where
␣ reliability ⬍0.4 ⫽ poor, 0.4 – 0.75 ⫽ good, ⬎0.75 excellent), c)
higher OM-3 total scores and physical suffering subscores were
associated with greater degrees of inflammation of the TM (OM-3
total vs otoscopy score, 8 grades [OS-8], ⱕ5 or ⱖ6, P ⬍ .06;
physical suffering subscore vs OS-8 ⱕ5 or ⱖ6; P ⬍ .001; ␹2 test; n ⫽
518), d) higher OM-3 total scores and physical suffering subscores
were associated with higher body temperatures, (OM-3 total score
vs body temperature, Spearman correlation, R ⫽ 0.21; P ⬍ .0001;
n ⫽ 518; physical suffering subscore vs body temperature, R ⫽
0.24; P ⬍ .0001; Spearman), and e) correlation between OM-3 total
score and 2 previously published symptom-severity scales: a
5-item ear treatment group scale described previously18 (R ⫽ 0.66;
P ⬍ .0001; n ⫽ 518; Spearman) and a previously published visual
analog scale19,20 (R ⫽ 0.73; P ⬍ .0001; n ⫽ 518, Spearman).
TM
Because none existed previously, we developed, as follows, a
categorization system (OS-8) to describe the appearance of the TM
in children with AOM.21,22 First, numerous photographs of the
TMs of children with and without AOM were obtained by our
investigators using a Storz tele-otoscope (Karl Storz Imaging, Go-
leta, CA) through a 3.0-mm reusable speculum held in place by a
Welch Allyn otoscope head (Welch Allyn, Inc, Skaneateles Falls,
NY). Photographs were printed in glossy format using a Sony
printer (Sony Electronics, Woodcliff Lake, NJ), and saved on a
server for future study.
The investigators studied the photographs and sorted them
initially into categories from normal (no erythema, no effusion,
normal structures) to severe (erythema, effusion, opacification,
bulla formation). The investigators then used the grading scale to
independently evaluate sets of photographs. At each iteration, the
investigators discussed their differences and improved on the
definitions. The scale was modified repeatedly until 6 investiga-
tors reached verbal agreement on the following 8 levels of sever-
ity: 0 ⫽ normal, or effusion without hyperemia; 1 ⫽ hyperemia
only, no effusion; 2 ⫽ hyperemia, air-fluid level, no opacification,
meniscus noted; 3 ⫽ hyperemia, complete effusion, no opacifica-
tion; 4 ⫽ hyperemia, opacification, air-fluid level observed, no
bulging; 5 ⫽ hyperemia, complete effusion, opacification, and no
bulging; 6 ⫽ hyperemia, bulging rounded doughnut appearance
of TM; and 7 ⫽ hyperemia with bulla formation. TMs rated
between 2 categories were given the higher score. Because we
were using very high-quality examination equipment, we were
often able to directly visualize bubbles or a fluid level within the
middle-ear space in ears categorized as grade 2 and 4, even when
the TM was erythematous and partially opacified. Intense illumi-
nation was provided by a hand-held otoscope supplied with a
fresh halogen lamp and fully-charged nickel cadmium batteries.
We also used the original Welch-Allyn reusable speculum, which
we consider superior to the Welch-Allyn disposable speculum,
which has numerous design flaws.23
OS-8 was further validated as follows. At pediatric meetings we
approached North American pediatricians (27% academic, 60%
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private, 13% other) who agreed to grade, by order of severity, a set
of high-quality prints of the OS-8 photoset displayed in random
order. Ninety-five of 122 pediatricians responded to the survey.
Statistical analysis of the results confirmed good agreement with
our predetermined levels of severity (R ⫽ 0.841; P ⬍ .001; N ⫽ 759
comparisons; Spearman).
Once OS-8 had been developed, investigators were trained to
grade the TMs using photosets and live ears of children with AOM
until their independent inter-observer agreements reached an ac-
ceptable level (Kappa ⬎0.6). The trained investigators then per-
formed otoscopic examinations on the subjects in this study, and
graded the TMs using OS-8. Whenever possible, diagnosis was
aided by photographs of subjects’ TMs taken with the tele-oto-
scope. In accordance with expert panel criteria,24 TM opacification
was required for inclusion in the study (OS-8 score ⱖ4 in at least
1 TM). Because blood vessel dilatation is a manifestation of in-
flammation, we excluded children from the study if they had no
evidence of TM hyperemia. When photographs were available, the
bullae were later inspected to verify their color, degree of opaci-
fication, location, size, and shape. In addition, any quadrants not
occupied by a bulla were observed for the presence of bulging.
Middle-Ear Effusion
Tympanograms were obtained on all subjects using a Welch-
Allyn TM262 Auto Tymp tympanometer and were categorized
using standard criteria25 except we used a more stringent defini-
tion of abnormal compliance (⬍0.2 mL.) based on results reported
by Le et al.26 Tympanograms were classified as: normal, type A
(compliance ⱖ0.2 mL, ⫺100 ⬍ middle-ear pressure ⱕ ⫹50 daPa);
bulging, type A⫹ (compliance ⱖ0.2 mL, middle-ear pressure ⬎
⫹50 daPa); middle-ear effusion, type B (compliance ⬍0.2 mL); and
retracted, type C (compliance ⱖ 0.2 mL, middle ear pressure ⬍
⫺99 daPa). For a diagnosis of AOM, children were required to
have evidence of middle-ear effusion by pneumatic otoscopy
and/or tympanometry and/or direct visualization of a fluid level.
Effusions observed in ears with a normal tympanogram were
typically characterized by the presence of either: a) a fluid-filled
bulla or bullae on a hyperemic opacified TM, or b) a nonbulging
hyperemic TM that under high illumination showed a partial
effusion, ie, an air-fluid level (opaque fluid) or air bubble(s).
Chart Review
Charts of the cases and controls were reviewed for follow-up
course of the illness and evidence of prior S pneumoniae heptava-
lent vaccine administration (Prevnar, Wyeth Laboratories, Madi-
son, NJ). Subjects were categorized as immunized if at least 1
month had elapsed between their last immunization and enroll-
ment in the study. S pneumoniae type-specific antibody titers were
considered high enough to provide partial or complete protection
if a) the first dose of vaccine was given between the ages of 2 and
12 months, and the child had received at least 3 doses, or b) if the
first dose of vaccine was given between the ages of 1 and 2 years,
and the child had received 2 doses, or c) if a single dose of vaccine
was given ⱖ2 years of age. Subjects were categorized as not
immunized if they had not received vaccine or had received any
number of doses less than the regimen described above. Children
began receiving heptavalent pneumococcal vaccine in our clinic in
October 2000.
Statistics
Forty-one of 518 cases of AOM were diagnosed with BM (7.9%).
Because the subjects with BM (median age: 4.3 years) were older
than the subjects without BM (median age: 18 months), each
subject with BM was paired with his/her closest AOM case with-
out BM, matched by age, race, and gender. The median difference
in ages between the subjects with BM and their matches was 7
weeks. We used the t test to compare total OM-3 scores of the
subjects with and without BM and the paired t test to compare
physical suffering scores for subjects with BM and their matches
(SAS statistical software). We used the ␹2 test to evaluate the
relation of bulla formation to categorical variables such as expo-
sure to tobacco smoke (none vs any smokers at home), season of
diagnosis (November–February vs March–October), and type of
tympanogram. We used the sign test27 to compare the groups on
all other variables. A P value ⬍ .05 was considered to be statisti-
cally significant. If bilateral AOM were present, only data from the
EXPERIENCE AND REASON
983
worst ear (considering the OS-8 score and tympanogram) were TABLE 2. Comparison of Matched Pairs Using the Sign Test
analyzed.
Variable Number of Pairs P
RESULTS BM Case Non-BM Ties
Of 41 matched pairs, 51% were male; 39% were Had Higher Subject Had
Value Higher Value
white, 27% Hispanic, 24% black, and 10% other. Bi-
lateral AOM was present in 29% of the BM subjects Physical suffering 22 9 10 .02
and 32% of the non-BM subjects. Two of the 41 BM Body temperature 26 15 0 .06*
Hours in child care 10 7 24 ⬎.10*
cases had bilateral BM. Two of the 41 BM cases (5%) Prior AOM 17 14 10 ⬎.10*
and 5 of the 41 non-BM controls (12%) displayed a Breastfeeding history 13 13 15 ⬎.10*
normal (type A) tympanogram. Five of the BM cases
* indicates not significant.
and 1 of the non-BM cases displayed an A⫹ or
positive pressure tympanogram. These comparisons
were not statistically significant by ␹2 analysis (see
Table 1). Total mean OM-3 scores were 13.5 ⫾ 4.7 for
the BM cases and 12.1 ⫾ 4.1 for the non-BM controls
(P ⫽ .05). The difference in OM-3 total scores be-
tween the groups was attributable mainly to the
physical suffering subscore. The mean physical suf-
fering subscore was 4.76 in subjects with AOM and
BM, versus 4.27 in subjects with AOM and non-BM,
a difference of 0.49 units or 0.29 standard deviation
(P ⬍ .02; Table 2). BM was not associated with du-
ration of breastfeeding, day care attendance, passive
tobacco smoke exposure, or prior history of ear in-
fections. Mean skin surface body temperatures were
marginally higher in the BM group (BM subjects
mean: 36.7 ⫾ 0.83°C; non-BM subjects mean: 36.4 ⫾
0.73°C; P ⫽ .06; see Table 2). Nine subjects with BM
had ⱖ37.3°C (equivalent to 38.3 rectal temperature)
at the time of initial evaluation; 4 subjects in the
non-BM group had initial temperatures this high.
Fig 1. Left TM of a 5-year-old boy who attended day care and had
Distribution of OS-8 scores for the non-BM a history of 7 AOM episodes. The child presented with upper
matched controls was as follows: 13 with a score of 4 respiratory tract infection symptoms, cough, earache, irritability,
(32%), 11 with a score of 5 (26%), and 17 with a score decreased appetite, and restless sleep. He was afebrile. The TM
of 6 (42%). Bulging of the portions of the TM not has a small bulla in the superior quadrant. The tympanogram was
occupied by the bulla was not initially recorded for flat. Note the collection of blood in the inferior pole of the bulla.
Note 2 other areas of gross hemorrhage in the posterior superior
any subject receiving an OS-8 score of 7. However, quadrant. Also seen is the typical bicycle spoke-like distribution of
photographs were available for review in 33 subjects hyperemic capillaries on the surface of the TM. This TM shows
with AOM and BM (see Fig 1, Fig 2, and Fig 3); of some fullness as can be appreciated by the slightly rounded ap-
these 32 (97%) had a bulging TM. Only 17 of 41 (42%) pearance of the dilated capillaries supplying blood to the center of
the TM, which appears more intensely inflamed.
of the non-BM pairs had a bulging TM.
Three of the 41 cases of AOM with BM were diag-
nosed with draining OM 22 to 60 days after initial tobacco smoke exposure, attendance at child care,
evaluation. This compares with one case of draining history of prior AOM, nor season of diagnosis was
OM on the 51st day after evaluation among the related to BM.
non-BM controls. There were no differences in his-
tory of tympanostomy tube placement, failure of DISCUSSION
treatment, or relapse between the BM cases and This study presents quantitative evidence that BM
non-BM controls. Only 7% percent of the BM cases cases may have more severe symptoms than non-BM
and 10% of the non-BM matched controls had re- cases when compared against the broad spectrum of
ceived sufficient numbers of doses of heptavalent AOM observed in clinical practice. Our data agree
pneumococcal vaccine to meet criteria for partial or with prior studies showing that BM occurs more
complete protection against the strains of S pneu- commonly in older children.13 A strength of this
moniae common to children. Neither breastfeeding, study is the case-control design and the large num-
ber of nonbullous AOM subjects available for match-
TABLE 1. Tympanogram Results ing and statistical comparison with the BM subjects.
Tympanogram Classification Another strength is the quality of otoscopic exami-
nations performed by trained investigators with as-
Type A Type A⫹ Type B Type C sistance of the OS-8 scoring system and high-resolu-
BM* 2 5 32 2 tion photographs taken with the tele-otoscope (Figs
AOM no bulla* 5 1 33 2 1–3).
* indicates not significant. Because the between-group differences were small
P ⬎ .30. for OM-3 and physical suffering (⬍0.5 standard de-

984 EXPERIENCE AND REASON

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Fig 2. Right TM of same child and same episode as in Fig 1. Three
bullae lie side by side adjacent to the malleus, which is not visible.
The TM shows significant bulging. The tympanogram was flat.
Bullae are filled with opaque, yellowish fluid. Some hemorrhage is
also noted.
Fig 3. Right TM with a large bulla occupying the inferior quad-
rants in a 3-year-old boy with a temperature 38.5°C who attended
day care and presented with cough and ear pain. He had a history
of 7 episodes of AOM. The tympanogram revealed an abnormal
compliance and a normal gradient. Note the distinct margins
between the bulla and the TM. The TM is bulging and mostly pale,
with a few small capillaries noted, except for the area of the pars
flaccida, which is intensely hyperemic.
viation), additional work will be needed to verify the
clinical significance of our findings. However, our
findings do support published clinical observations
in which authors have described BM as having more
severe symptoms than AOM without bulla forma-
tion. These results are also supported by the finding
that 97% of the TM photographs from the subjects
with BM showed bulging of the portions of the TM
that were not obscured by the bulla, whereas only
42% in the control group showed bulging of the TM.
Bulging is generally considered to be a more severe
presentation of AOM.
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A possible weakness of the study is the lack of data
on the validity of tympanometry for the assessment
of middle-ear effusion in AOM. We categorized tym-
panograms using methods based on articles by
Finitzo25 and Le.26 However, these authors did not
specifically study subjects with AOM, but assessed
children immediately before the insertion of pressure
equalizing tympanostomy tubes. Our study empha-
sizes the need for additional work on the reliability
of tympanometry as a specific predictor of middle-
ear effusion in AOM.
We and others have previously shown that a mid-
dle-ear culture positive for S pneumoniae is often
associated with more severe clinical symptoms of
AOM, higher levels of inflammatory mediators,
and/or otoscopic evidence of a more inflamed
TM.28 –30 The present study provides no bacteriologic
data; however, others have shown that S pneumoniae
is more often the etiologic agent in BM than in AOM
without BM.14,15 Palmu14 detected S pneumoniae in
32.4% of ears with BM versus 14.5% of ears with no
BM. Coffey1 cultured S pneumoniae in 7 of 10 ears
with BM. Rosenblut15 detected S pneumoniae in 20 of
27 (74%) cases with BM compared with 43 of 143
(30%) cases of AOM without BM (P ⬍ .001). It should
be noted that the children with BM in our study were
older than the others, and many had not had an
opportunity to receive the heptavalent pneumococ-
cal vaccine. We speculate that S pneumoniae might be
responsible for the greater degree of inflammation
and more severe symptoms in some of our cases as
well.
Clinicians have been encouraged to consider an
option of watchful waiting using symptom manage-
ment without prescribing immediate antibiotics
for children with mild AOM, because the literature
indicates that most such children will recover with-
out antimicrobial treatment.31–32 This approach
would facilitate the judicious use of antimicrobial
agents currently recommended by the Centers for
Disease Control and Prevention.33 Some children
experiencing painful AOM with BM may not be
successful candidates for a watchful-waiting ap-
proach to treatment, because parents may resist
postponement of antibiotic therapy in children who
are more symptomatic. If antibiotic treatment is ini-
tiated for such children, caution should be used in
selecting the appropriate agent. The literature indi-
cates that S pneumoniae is more often the pathogen
responsible for AOM with BM, and this organism
may be resistant to penicillin and other antibiotics in
communities where antibiotics have been used ex-
tensively.
CONCLUSIONS
When compared with children with AOM without
BM, children with AOM and BM were older, had
higher symptom scores, and had more severe oto-
scopic findings in the portions of the TM not occu-
pied by the bulla. Because some children with BM
may have significant pain at the time of initial eval-
uation, the clinician should pay special attention to
pain management in such cases. Children with pain-
ful BM may not be successful candidates for a watch-
EXPERIENCE AND REASON
985
ful-waiting approach, because parents may resist
postponement of antibiotic therapy in children who
are more symptomatic.
David P. McCormick, MD
Kokab A. Saeed, MD
Carmen Pittman, BA
Division of General Academic Pediatrics
University of Texas Medical Branch at Galveston
Galveston, TX 77555-1119
Constance D. Baldwin, PhD
Division of Education/Research
University of Texas Medical Branch at Galveston
Galveston, TX 77555-0344
Norman Friedman, MD
Department of Otolaryngology
Children’s Hospital
Denver, CO 80218
Davis C. Teichgraeber, BA
University of Texas Medical Branch at Galveston
Galveston, TX 77555-1119
Tasnee Chonmaitree, MD
Division of Infectious Diseases
University of Texas Medical Branch at Galveston
Galveston, TX 77555-0371
ACKNOWLEDGMENTS
This work was supported by grant M01 RR 00073 from the
National Center for Research Resources and grant R01 HS10613-02
from the Agency for Healthcare Research and Quality. Eiizabeth
Diaz, PA, assisted with data collection, and Mary H. Whitby
assisted in preparation of the manuscript.
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Longstanding Obliterative
Panarteritis in Kawasaki Disease:
Lack of Cyclosporin A Effect
ABSTRACT. Kawasaki disease is a childhood vasculi-
tis of medium-sized vessels, affecting the coronary arter-
ies in particular. We have treated a therapy-resistant
child who met all diagnostic criteria for Kawasaki dis-
ease. After the boy was given intravenous immunoglobu-
Received for publication Feb 20, 2003; accepted Jun 6, 2003.
Address correspondence to Taco W. Kuijpers, MD, PhD, Emma Children’s
Hospital, Academic Medical Center (G8 –205), Meibergdreef 9, 1105 AZ
Amsterdam, the Netherlands. E-mail: t.w.kuijpers@amc.uva.nl
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
 Bullous Myringitis: A Case-Control Study
David P. McCormick, Kokab A. Saeed, Carmen Pittman, Constance D. Baldwin,
Norman Friedman, Davis C. Teichgraeber and Tasnee Chonmaitree
Pediatrics 2003;112;982
DOI: 10.1542/peds.112.4.982

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 Bullous Myringitis: A Case-Control Study
David P. McCormick, Kokab A. Saeed, Carmen Pittman, Constance D. Baldwin,
Norman Friedman, Davis C. Teichgraeber and Tasnee Chonmaitree
Pediatrics 2003;112;982
DOI: 10.1542/peds.112.4.982

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/112/4/982

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60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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