Management of Blood on Intact Tympanic Membrane from Coughing
For blood on an intact tympanic membrane caused by coughing, the recommended management is observation and keeping the ear dry, as these cases typically resolve spontaneously without specific intervention.
Assessment and Diagnosis
- Carefully examine the tympanic membrane using otoscopy to confirm the presence of blood without perforation 1
- Distinguish between intra-tympanic membrane hemorrhage (blood within the tympanic membrane layers) and hemotympanum (blood in the middle ear cavity) 2
- Assess for any modifying factors that may influence management, such as diabetes, immunocompromised state, or anticoagulant therapy 1
- Consider tympanometry if swelling or discomfort don't preclude its use, as a normal type A tracing suggests an intact tympanic membrane 1
Management Approach
Primary Management
- Observation is appropriate for asymptomatic blood on an intact tympanic membrane, as most cases resolve spontaneously 3
- Keep the ear dry to prevent infection by using ear plugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until resolved 3
- Avoid irrigation of the ear canal as this could potentially damage the tympanic membrane or introduce infection 3
Important Precautions
- Avoid using cotton-tipped applicators in the ear canal as they may cause further trauma 3
- Avoid pneumatic otoscopy which could potentially worsen the condition 4
- If topical medications are needed for any reason, use only non-ototoxic preparations 1, 3
Follow-Up Recommendations
- Re-evaluate if symptoms (hearing loss, pain, fullness) persist beyond 2 weeks 3, 2
- Most intra-tympanic membrane hemorrhages resolve spontaneously within 1 month without specific treatment 2
Special Considerations
When to Consider Additional Treatment
- If the patient has a bleeding disorder (like immune thrombocytopenic purpura), the bleeding may be more significant and require treatment of the underlying condition 5
- Consider systemic antibiotics only if there are signs of infection or in patients with specific host factors such as diabetes or immunocompromised state 3
Warning Signs Requiring Specialist Referral
- Persistent pain, vertigo, facial paralysis, or fever may indicate complications and require ENT consultation 6
- If symptoms worsen or if there are signs of middle ear infection developing, prompt reassessment is necessary 1
Clinical Course and Prognosis
- Blood within the tympanic membrane typically resolves spontaneously without permanent damage 2
- Hearing loss, if present, is usually mild and temporary, resolving as the blood is reabsorbed 2
- Coughing-induced hemorrhage is likely caused by abrupt increases in middle ear pressure, similar to what occurs with sneezing 5