What causes blood on an intact tympanic membrane?

Causes of Blood on an Intact Tympanic Membrane

Blood on an intact 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

Common Etiologies

• Granulation tissue or granuloma 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
• Trauma to the tympanic membrane without perforation can cause intra-tympanic membrane (iTM) hemorrhage, where bleeding occurs between the layers of the tympanic membrane 3
• Barotrauma, particularly from scuba diving or rapid changes in pressure, can cause blood to appear within the tympanic membrane 3
• Bleeding disorders such as immune thrombocytopenic purpura (ITP) can cause spontaneous hemotympanum even with an intact tympanic membrane 4
• Complications of acute otitis media can present with a hyperemic, dull, bulging but intact tympanic membrane with blood visible behind it 5

Clinical Assessment

• Otoscopic examination is essential to distinguish between blood within the tympanic membrane itself, blood in the middle ear cavity (hemotympanum), and blood from a perforated tympanic membrane 1
• When examining the tympanic membrane, look specifically for:
  • Retraction pockets
  • Ossicular erosion
  • Areas of atelectasis and atrophy
  • Presence of tympanostomy tubes 1
• Avoid pneumatic otoscopy when perforation is suspected, as it may cause further damage 6
• Assess for symptoms such as otalgia, aural fullness, and tinnitus, which commonly accompany intra-tympanic membrane hemorrhage 3

Management Based on Etiology

For Granulation Tissue/Granuloma with Tympanostomy Tubes

• The treatment of choice is a topical quinolone drop, with or without dexamethasone 2, 1
• Systemic antibiotics should not be prescribed for this condition 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 2

For Trauma-Related Hemorrhage

• Most intra-tympanic membrane hemorrhages resolve spontaneously without specific treatment, usually within 1 month 3
• Keep the ear dry to prevent infection when there is concern about perforation 7
• Avoid ear irrigation and use only non-ototoxic preparations when treating ear conditions in patients with suspected perforation 7, 6

For Bleeding Disorder-Related Hemorrhage

• Treat the underlying bleeding disorder (e.g., high-dose corticosteroids for ITP) 4
• Consider prophylactic antibiotics if there is concern about secondary infection 4

Warning Signs Requiring Specialist Referral

• Vertigo, nausea, and vomiting accompanying the bleeding, which may suggest disruption of the ossicular chain or inner ear involvement 8
• Significant hearing loss (conductive hearing loss >30 dB) 8
• Retroauricular swelling, which may indicate complications such as mastoiditis or subperiosteal abscess 5
• Persistent bleeding or discharge that does not respond to initial treatment 6

Prognosis

• Most intra-tympanic membrane hemorrhages resolve spontaneously without permanent hearing loss 3
• Granulation tissue associated with tympanostomy tubes typically responds well to topical therapy 2
• Complications are rare but can be serious if the bleeding is related to underlying otitis media with an intact but bulging tympanic membrane 5