What to do for a patient with continuous ear bleeding?

Management of Continuous Ear Bleeding

For a patient with continuous ear bleeding, immediately apply direct pressure with gauze or cotton to the external auditory canal while simultaneously assessing for life-threatening hemorrhage, airway compromise, and hemodynamic instability—if any of these are present, the patient requires emergent hospital evaluation and potential surgical intervention. 1, 2

Immediate Assessment and Stabilization

Critical Initial Actions

• Apply firm, sustained compression to the bleeding site using gauze packing or cotton pledgets soaked in topical vasoconstrictors (epinephrine 1:1000) for at least 5-10 minutes 1, 3
• Assess hemodynamic status immediately: check for tachycardia, hypotension, altered consciousness, or signs of hypovolemic shock 4
• Evaluate bleeding severity by documenting duration, volume (blood from one ear vs. both ears, blood in mouth/throat), and any associated symptoms like dizziness or syncope 4, 1

Triage Decision Points

Emergent hospital/ED evaluation is required if ANY of the following are present: 1

• Hemodynamic instability (hypotension, tachycardia, orthostasis)
• Airway compromise
• Bleeding duration >30 minutes over 24 hours
• Massive bleeding requiring transfusion
• Signs of skull base fracture or head trauma
• Altered mental status

Ambulatory management is acceptable only if: 1

• Minor bleeding without hemodynamic compromise
• No airway concerns
• Patient is alert and stable

Diagnostic Evaluation

Essential History Elements

Document the following risk factors and associated conditions: 1

• Trauma history: recent head injury, ear instrumentation (cotton swabs, earpicks), myringotomy, or ear surgery 5, 6
• Anticoagulation status: warfarin, DOACs (apixaban, rivaroxaban, dabigatran), antiplatelet agents (aspirin, clopidogrel) 4, 1
• Bleeding disorders: personal or family history of coagulopathy, thrombocytopenia 1
• Chronic ear disease: history of chronic otitis media, cholesteatoma, or prior ear surgeries 6
• Systemic conditions: hypertension, liver disease, kidney disease, anemia 4, 1

Physical Examination

• Otoscopic examination to identify the bleeding source: external auditory canal laceration, tympanic membrane perforation, middle ear pathology, or hemotympanum 3, 7
• Assess for skull base fracture signs: Battle's sign (mastoid ecchymosis), hemotympanum, CSF otorrhea 7
• Vital signs monitoring: blood pressure, heart rate, oxygen saturation 4

Treatment Algorithm

First-Line Interventions

1. Direct pressure and packing: 2, 3

   • Insert Merocel packing or gauze soaked with epinephrine (1:1000) into the external auditory canal
   • Apply external pressure dressing with Kerlix gauze if needed
   • Maintain pressure for 10-15 minutes minimum

2. Topical hemostatic agents: 3

   • Epinephrine-soaked cottonoids (1:1000 concentration)
   • Hydrogen peroxide irrigation for clot removal and hemostasis
   • Avoid aggressive suctioning that may worsen bleeding

3. Cauterization (if bleeding site is visualized and accessible): 3

   • Monopolar or bipolar cautery for discrete bleeding vessels
   • Only after adequate anesthesia and visualization

Management of Anticoagulated Patients

For non-life-threatening bleeding: 4, 1

• Do NOT give the next scheduled dose of anticoagulant/antiplatelet medication while bleeding is active
• Initiate local hemostatic measures first (packing, pressure, cautery) before considering reversal
• Use resorbable packing preferentially in anticoagulated patients to avoid trauma from removal 4

For severe or life-threatening bleeding: 4

• Hold anticoagulation immediately
• Administer appropriate reversal agents:
  • Warfarin: 4-factor prothrombin complex concentrate (PCC) + IV vitamin K
  • DOACs: 4-factor PCC; idarucizumab for dabigatran specifically
  • Heparin/LMWH: protamine sulfate
  • Antiplatelet agents: platelet transfusion (though may be ineffective if drug still active)
• Consult the prescribing physician managing anticoagulation before full reversal 4

Refractory Bleeding Management

If bleeding persists despite packing and local measures: 1, 2

• Consider vascular injury, particularly aberrant internal carotid artery or pseudoaneurysm in patients with chronic ear disease or recent trauma 5, 6
• Obtain urgent imaging: CT angiography or conventional angiography to identify vascular anomalies 5, 6
• Surgical/interventional options: 6
  • Endovascular embolization for pseudoaneurysm
  • Surgical arterial ligation with revascularization if needed
  • Mastoidectomy for infected/necrotic tissue causing vascular erosion

Critical Pitfalls to Avoid

• Never assume ear bleeding is benign—it can indicate skull base fracture, vascular injury, or life-threatening hemorrhage 2, 5
• Do not blindly pack without visualization in trauma patients, as this may worsen unrecognized skull base fractures 7
• Do not reverse anticoagulation reflexively—use local measures first unless bleeding is life-threatening 4, 1
• Do not miss aberrant carotid artery—pulsatile middle ear mass or history of chronic otitis media should raise suspicion before any instrumentation 5, 6
• Do not discharge without clear follow-up plan—document intervention outcomes within 30 days 1

Patient Education and Follow-Up

• Instruct patients on warning signs requiring immediate return: increased bleeding, dizziness, confusion, severe headache 1
• Provide packing care instructions: timing of removal (if non-resorbable), activity restrictions, signs of infection 1
• Arrange ENT follow-up within 24-48 hours for persistent or recurrent bleeding 1