What is the management for blood on the tympanic membrane?

Management of Blood on the Tympanic Membrane

For blood on the tympanic membrane, the treatment of choice is a topical quinolone drop, with or without dexamethasone, particularly when caused by granulation tissue or granuloma. 1

Causes and Assessment

• Blood on the tympanic membrane is most commonly caused by granulation tissue or granuloma at the junction of a tympanostomy tube with the tympanic membrane, trauma, barotrauma, or bleeding disorders 1
• Granulation tissue at the junction of a tympanostomy tube with the tympanic membrane occurs in approximately 4% of children with tubes, presenting as persistent painless otorrhea that is pink or bloody 2, 1
• Careful otoscopic examination is essential to distinguish between blood within the tympanic membrane itself, blood in the middle ear cavity, and blood from a perforated tympanic membrane 1
• When examining the tympanic membrane, specifically look for retraction pockets, ossicular erosion, and areas of atelectasis and atrophy 1

Management Approach

For Intact Tympanic Membrane

• Apply topical quinolone drops (ofloxacin or ciprofloxacin) with or without dexamethasone 1
• Ofloxacin has been shown to have less impact on tympanic membrane healing compared to ciprofloxacin 3
• Avoid systemic antibiotics unless there are signs of severe infection (high fever, severe otalgia, toxic appearance) 2

For Non-Intact Tympanic Membrane (Perforation)

• Use only non-ototoxic topical preparations to prevent potential sensorineural hearing loss 2, 4
• Ofloxacin 0.3% otic solution is specifically approved for use in patients with non-intact tympanic membranes and is not associated with ototoxicity 5
• Avoid potentially ototoxic preparations containing aminoglycosides like neomycin or gentamicin 4
• Avoid irrigation and pneumatic otoscopy as these can worsen the injury or introduce infection 4

For Ear Canal Edema

• If edema prevents drop entry or if most of the tympanic membrane cannot be visualized, consider placing a wick in the ear canal 2, 4
• Use compressed cellulose wicks or ribbon gauze rather than cotton balls 2, 4
• Consider moistening and expanding the wick with an aqueous solution (water, saline, aluminum acetate) before the first application of an otic suspension 2
• Remove the wick once ear canal edema subsides, typically within 24 hours to a few days 2, 4

For Granulation Tissue or Granuloma

• Topical quinolone drops with or without dexamethasone is the treatment of choice 2, 1
• Systemic antibiotics should not be prescribed for granulation tissue or granuloma at the junction of a tympanostomy tube with the tympanic membrane 2, 1
• Reassure patients/caregivers that the bloody discharge is not a cause for concern, should respond to therapy, and will not damage the ear or hearing 2

Special Considerations

For Persistent Drainage

• Assess for obstructing debris in the ear canal or in the tympanostomy tube that can impair drug delivery 2
• Consider culture of persistent drainage to help target future therapy, detecting pathogens such as fungi and MRSA 2
• For persistent otorrhea despite topical therapy, consider ear wicks to improve penetration of the drops through the ear canal 2

For Fungal Infections

• Suspect fungal otitis externa (otomycosis) if the patient fails to respond to initial topical antibiotic therapy 2, 4
• Topical therapy with irrigating solutions of boric acid, acetic acid, or azole cream may be effective in eradicating Aspergillus otomycosis 2
• For refractory cases and in contexts of perforated tympanic membranes, use of voriconazole, posaconazole, or itraconazole may be appropriate 2

Follow-up and Monitoring

• Reassess the patient within 48-72 hours if they fail to respond to the initial therapeutic option 2, 4
• For patients with tympanostomy tubes, routine water precautions (use of earplugs or headbands, avoidance of swimming or water sports) are not necessary 2

Common Pitfalls and Caveats

• Never use potentially ototoxic preparations in patients with perforated tympanic membranes 4
• Avoid irrigation in patients with perforated tympanic membranes 4
• Be aware that ciprofloxacin + dexamethasone ear drops have been associated with higher rates of tympanic membrane perforations than ofloxacin alone 3
• Use caution with aural toilet in diabetic or immunocompromised patients, and consider atraumatic cleaning with aural suctioning under microscopic guidance 4