What causes blood on the tympanic membrane?

Causes of Blood on the Tympanic Membrane

Blood on the tympanic membrane is most commonly caused by granulation tissue or a granuloma at the junction of a tympanostomy tube with the tympanic membrane, trauma, barotrauma, or bleeding disorders. 1

Common Causes of Blood on the Tympanic Membrane

• Granulation tissue/granuloma: When children with tympanostomy tubes present with persistent painless otorrhea that is pink or bloody, the most common cause (occurring in about 4% of children with tubes) is granulation tissue or a granuloma at the junction of the tympanostomy tube with the tympanic membrane 1

• Trauma:

  • Blunt head trauma can cause intra-tympanic membrane hemorrhage without perforation 2
  • Traumatic injury to the ear can cause bleeding within or behind the tympanic membrane 3

• Barotrauma:

  • Descent barotrauma during activities like scuba diving can lead to hemorrhage within the tympanic membrane 2
  • Pressure changes during air travel or deep water diving can cause blood vessels in the tympanic membrane to rupture 2

• Bleeding disorders:

  • Anticoagulant therapy can lead to spontaneous hemotympanum (blood in the middle ear or ecchymosis of the tympanic membrane) 4
  • Immune thrombocytopenic purpura and other blood disorders can cause hemotympanum presenting with hearing loss 5

• Spontaneous causes:

  • Epistaxis (nosebleed) can sometimes lead to blood appearing on the tympanic membrane through the Eustachian tube 2
  • Idiopathic hemotympanum can occur in the presence of chronic otitis media 4

Clinical Presentation and Assessment

• Patients with intra-tympanic membrane hemorrhage commonly present with otalgia (ear pain) and ear fullness 2

• Otoscopic examination is essential to distinguish between:

  • Blood within the tympanic membrane itself
  • Blood in the middle ear cavity (hemotympanum)
  • Blood from a perforated tympanic membrane 6

• Pneumatic otoscopy should be used to assess tympanic membrane mobility, which helps differentiate between various conditions 6

• When examining the tympanic membrane, look specifically for:

  • Retraction pockets
  • Ossicular erosion
  • Areas of atelectasis and atrophy 1

Management Approach

• For granulation tissue or granuloma at the junction of a tympanostomy tube with the tympanic membrane:

  • The treatment of choice is a topical quinolone drop, with or without dexamethasone 1
  • Systemic antibiotics should not be prescribed 1
  • Caregivers should be reassured that the bloody discharge is not a cause for concern, should respond to therapy, and will not damage the ear or hearing 1

• For intra-tympanic membrane hemorrhage without perforation:

  • Most cases resolve spontaneously without specific treatment, usually within 1 month 2
  • Pure tone audiometry typically shows no or minimal conductive hearing loss 2

• For hemotympanum related to anticoagulant use:

  • Conservative treatment may include a course of antibiotics, anticongestants, and temporary interruption of anticoagulant therapy 4
  • Resolution typically occurs within 3 weeks with appropriate management 4

Special Considerations

• In patients with bleeding disorders, hemotympanum can develop rapidly and may cause unusual symptoms 5

• Avoid irrigation and pneumatic otoscopy in cases of suspected tympanic membrane perforation 7

• For chronic or recurrent cases, further evaluation may be needed to rule out underlying conditions:

  • Temporal bone computed tomography can help identify thickening of the tympanic membrane without soft tissue density in the tympanic cavity 2
  • Audiometric testing may be necessary to assess for conductive hearing loss 4

Remember that while blood on the tympanic membrane may appear concerning, in many cases it resolves spontaneously with minimal intervention, particularly when associated with minor trauma or barotrauma 2.