What is the appropriate workup for a patient presenting with bleeding from the ears?

From the Guidelines

The appropriate workup for a patient presenting with bleeding from the ears begins with a thorough history and physical examination to determine the cause and severity, and according to the most recent guideline 1, immediate bleeding control procedure is recommended for patients with an obvious bleeding source. First, assess for trauma, as this is a common cause, particularly looking for signs of head injury, temporal bone fractures, or direct ear trauma. Otoscopic examination should be performed to visualize the ear canal and tympanic membrane, distinguishing between external ear bleeding and middle ear hemorrhage. Neurological examination is essential to evaluate for signs of intracranial injury, especially with trauma. Some key points to consider in the workup include:

• Laboratory tests should include complete blood count, coagulation studies (PT, PTT, INR), and type and cross-match if significant blood loss is present.
• Imaging studies are crucial, with CT scan of the head and temporal bones being the first-line imaging modality to assess for fractures, foreign bodies, or intracranial pathology, as suggested by previous guidelines 1.
• MRI may be indicated if soft tissue abnormalities are suspected.
• Audiometric testing should be considered to evaluate hearing loss.
• Management depends on the cause but may include keeping the ear dry, antibiotic therapy for infection, removal of foreign bodies, or surgical intervention for trauma.
• Consultation with otolaryngology is recommended for most cases of ear bleeding, and neurosurgery consultation should be obtained if intracranial injury is suspected, as also recommended in the context of cerumen impaction 1. This systematic approach ensures proper diagnosis and treatment while preventing complications such as hearing loss or infection.

From the Research

Initial Assessment

• The patient presenting with bleeding from the ears requires a thorough initial assessment to determine the cause and severity of the injury.
• This assessment should include a detailed history of the injury, including the mechanism of injury, and a physical examination to identify any signs of trauma or other associated injuries.

Possible Causes

• Basilar skull fractures are a possible cause of bleeding from the ears, and can be associated with other symptoms such as cerebrospinal fluid rhinorrhea or otorrhea, periorbital ecchymosis, and cranial nerve injuries 2, 3.
• Other possible causes of ear bleeding include middle ear injuries, which can be addressed during the treatment process 4.

Diagnostic Imaging

• If there are any clinical signs of a basilar skull fracture, neurological deficits, or limited consciousness, a CT scan should be performed to rule out a basilar skull fracture and accompanying pathologies 2.
• CT angiography should also be performed if vascular injury is suspected 2.

Treatment

• The treatment of bleeding from the ears depends on the underlying cause and severity of the injury.
• For basilar skull fractures, treatment is usually interdisciplinary and depends mainly on the accompanying injuries and possible complications 2.
• A purely conservative approach with close controls (with imaging) is often sufficient, while the surgical approach is primarily used to treat possible complications, such as intracerebral bleeding 2.
• For middle ear injuries, primary repair remains feasible in most cases, but delayed and staged reconstruction may be necessary to achieve successful results 4.

Hemostasis

• Hemostasis may fail due to deficiencies of platelets, the plasma coagulation protein system, or endothelial disturbances 5.
• A precise diagnosis and appreciation of the tempo of the disorder will guide specific therapy 5.

Control of Bleeding

• Tourniquets, hemostatic dressings, and direct manual pressure are methods that can be used to control bleeding, although the certainty of evidence is very low and often relies on indirect evidence and poorly controlled studies 6.