Shagrination during Acute Otitis Media
3-year-old patient with an upper respiratory infection presented with acute onset of left otalgia. Examination of the ear revealed acute otitis media (AOM),1 characterized by a purulent middle ear effusion with an erythematous, bulging tympanic membrane (TM) (Figure 1, A); a course of amoxicillin was initiated. On day 2, findings of the examination revealed cobblestoning of the TM (Figure 1, B), or shagrination, from shagreen (the alternate spelling is chagrination2). On day 3, the shagrination and bulging had resolved leaving a middle ear effusion (Figure 1, C). Shagrination of the TM is not an uncommon finding in pediatric practice, but the significance is not clear. During a study of AOM, written, informed consent was obtained to photograph the TM of 17 patients enrolled on day of diagnosis (day 1) and days 2 and 3. Shagrination occurred within 1-2 days of recognition of a bulging TM in 6 patients (Figure 2, available at www.jpeds.com). Patient 5 had shagrination of the right ear at presentation; patients 4, 5, and 6 did not receive antimicrobials. After the development of shagrination, the bulging appearance subsided, even in the 3 patients not treated with antimicrobials. Although the mechanism is unknown, shagrination presumably results from decompression of the middle ear space and heralds the resolution of the bulging TM. It may be that shagrination occurs once the TM has reached its
“peak” of bulging. The cobblestone and/or scaly appearance develops as the TM returns to a neutral position. Shagrination may occur during the course of AOM, represents decompression of the middle ear, and heralds the resolution of the infection. n Supported by Pediatric Associates of Charlottesville, Plc and the Pendelton Pediatric Infectious Disease Laboratory at the University of Virginia. The authors declare no conflicts of interest.
Carlos E. Armengol, MD Pediatric Associates of Charlottesville, Plc Department of Pediatrics
J. Owen Hendley, MD Department of Pediatrics University of Virginia School of Medicine Charlottesville, Virginia
References 1. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99. 2. Lundberg T, Hellstrom S, Sandstrom H. Development and validation of a new grading scale for otitis media. Pediatr Infect Dis J 2013;32: 341-5.
Figure 1. A purulent middle ear effusion with A, an erythematous, bulging tympanic membrane on the day of diagnosis (day 1) followed by B, a cobblestone appearance (day 2) known as shagrination and C, resolution of the bulging tympanic membrane (day 3) with a residual middle ear infection.
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Figure 2. Images of five patients with acute otitis media that developed shagrination. Images begin on day of diagnosis (Day 1). Patient 5 had shagrination of the right ear at presentation. Patients 4, 5 and 6 did not receive antimicrobials.
Armengol and Hendley