What is the initial management for bullous myringitis (inflammation of the eardrum with blisters)?

Initial Management of Bullous Myringitis

The initial management of bullous myringitis should include draining the hemorrhagic bullae on the tympanic membrane and administering appropriate antibiotics targeting common acute otitis media pathogens. 1

Understanding Bullous Myringitis

Bullous myringitis is characterized by:

• Painful vesicles or blisters on the tympanic membrane and medial external auditory canal
• Often preceded by upper respiratory infection
• Commonly occurs in winter months
• Can cause severe ear pain and occasionally sensorineural hearing loss
• Represents a special form of acute otitis media with more severe symptoms 2

Management Algorithm

Step 1: Pain Management

• Address severe pain immediately
• Analgesics appropriate for pain intensity (acetaminophen or NSAIDs)
• Consider stronger pain medication if needed due to the typically severe pain associated with this condition

Step 2: Drainage of Bullae

• Carefully pierce bullae with a sterile needle, with the bevel facing up 3
• Select a site where fluid will drain by gravity to prevent refilling
• Leave the blister roof intact as it serves as a natural biological dressing
• Gently apply pressure with sterile gauze to facilitate drainage 3
• After drainage, cleanse the area with antimicrobial solution

Step 3: Antibiotic Therapy

• Prescribe antibiotics targeting common acute otitis media pathogens:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis 1
• Use standard acute otitis media antibiotic regimens (amoxicillin or amoxicillin-clavulanate)

Step 4: Topical Treatment

• Consider topical antibiotics if external canal is involved
• Avoid ear drops that might mask symptoms or complicate assessment

Special Considerations

For Severe Cases

• If sensorineural hearing loss is present, consider systemic corticosteroids, though evidence for their benefit is limited 4
• For extremely painful cases, consider short-term systemic corticosteroids to reduce inflammation

Monitoring and Follow-up

• Schedule follow-up within 48-72 hours to assess response to treatment
• Monitor for resolution of pain and hearing changes
• Symptoms typically resolve within 1-2 days in most cases 2

Common Pitfalls to Avoid

1. Failure to drain bullae: Leaving painful bullae intact can prolong severe pain
2. Removing the blister roof: This can increase risk of infection and delay healing
3. Inadequate pain management: The pain of bullous myringitis can be excruciating and requires appropriate analgesia
4. Missing associated hearing loss: Always assess for sensorineural hearing loss which may require additional treatment
5. Confusing with chronic granular myringitis: Bullous myringitis is acute and associated with middle ear inflammation, while granular myringitis is typically chronic and an external ear pathology 5

Bullous myringitis typically resolves quickly with appropriate treatment, and the short-term outcome is generally good, with symptoms relieved within 1-2 days in most cases 2.