Bullous Myringitis - Clinical presentation & Management

Bullous myringitis is a direct inflammation and infection of the tympanic membrane secondary to a viral or bacterial agent. Vesicles or bullae filled with blood or serosanguinous fluid on an erythematous tympanic membrane are the hallmarks. Frequently, a concomitant otitis media with effusion is noted.
Typical pathogens are the same as seen in Acute otitis media.

Clinical Presentation: The onset of bullous myringitis is preceded by an upper respiratory tract infection and is heralded by sudden onset of severe ear pain, scant serosanguinous drainage from the ear canal, and frequently some degree of hearing loss.
Otoscopy reveals bullae on either the inner or outer surface of the tympanic membrane.

Bullous Myringitis. A large fluid-filled bulla is seen distorting the surface of the tympanic membrane.

Patients presenting with fever, hearing loss, and purulent drainage are more likely to have concomitant infections, such as Otitis media and otitis externa .

Management: Differentiation between viral and bacterial etiologies for tympanic membrane bullae is not necessary. Although most episodes resolve spontaneously, many physicians prescribe antibiotics. Warm compresses, topical or strong analgesics, and oral decongestants provide symptomatic relief. Referral is not necessary in most cases unless rupture of the bullae is required for pain relief.


Clinical Pearls
1. In case of children instruct parents that tympanic membrane rupture may occur with sudden resolution of the pain and drainage from the ear canal.
2. Carefully differentiate tympanic membrane bullae from cholesteatomas or herpetic vesicles.
3. Facial nerve paralysis associated with clear, fluid-filled tympanic membrane vesicles is characteristic of herpes zoster oticus .