What are the symptoms and treatments of tympanic membrane issues?

Tympanic Membrane Pathology: Symptoms and Treatment

I cannot provide images, but I can describe the key visual findings and clinical features you should recognize when examining tympanic membranes with various pathologies.

Visual Findings on Otoscopic Examination

Normal vs. Pathologic Appearance

A normal tympanic membrane appears translucent, pearly gray, and mobile with pneumatic otoscopy. 1 When pathology is present, you'll observe distinct changes that correlate with underlying middle ear disease.

Key Pathologic Features to Identify

Acute Otitis Media (AOM):

• Bulging, cloudy, immobile tympanic membrane is highly associated with acute otitis media 2
• Rapid onset of inflammation with distinctly bulging membrane 3
• Erythema alone (without bulging or immobility) is often from viral infection, crying, or cerumen removal attempts and should not be the sole basis for diagnosing AOM 2
• May present with fever and intense earache, though these "classic" findings are often absent even in confirmed cases 2

Otitis Media with Effusion (OME):

• Middle ear fluid visible behind the tympanic membrane without signs of acute infection 3
• No fever, no severe ear pain, no bulging membrane 3
• Reduced or absent mobility on pneumatic otoscopy 3
• Tympanic membrane may appear retracted or have air-fluid levels 1

Structural Changes from Chronic Disease:

• Retraction pockets (especially posterosuperior) - correlate with cholesterol granuloma, cholesteatoma, and ossicular pathology 1, 4
• Myringosclerosis (white plaques) - correlates with granulation tissue and ossicular pathology 4
• Perforation - correlates with ossicular pathology 4
• Atelectasis (severe retraction/collapse) - indicates chronic underventilation 1
• Tympanosclerosis - calcific deposits in the membrane 4

Blood on the Tympanic Membrane:

• Most commonly caused by granulation tissue at tympanostomy tube site, trauma, barotrauma, or bleeding disorders 5
• Granulation tissue presents with persistent painless otorrhea that is pink or bloody 5
• Hemorrhage within the membrane correlates with underlying granulation tissue 4

Common Pitfalls in Diagnosis

Critical examination requirements:

• Adequate visualization requires cerumen removal if the tympanic membrane is obscured 1, 2
• Use an otoscope with fresh bulb and good power source 2
• Always perform pneumatic otoscopy to assess mobility - this is essential for distinguishing OME from normal ears 3, 5
• If uncertainty exists about structural abnormalities, use an otomicroscope for detailed evaluation 1

A normal-appearing tympanic membrane does not exclude middle ear pathology - nearly half of temporal bones with middle ear disease showed no tympanic membrane changes 4. Consider tympanometry and other diagnostic tools when clinical suspicion is high despite normal otoscopy 4.

Treatment Approach

For Acute Otitis Media:

• First-line therapy: amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 3
• Duration: 5 days for adults and children >2 years; 8-10 days for children <2 years 3
• For penicillin allergy: erythromycin-sulfafurazole, macrolides, or doxycycline (though higher failure rates due to resistance) 3

For Otitis Media with Effusion:

• Watchful waiting for 3 months from diagnosis is recommended for OME resulting from upper respiratory infections 3
• Do not prescribe antibiotics for routine OME - they lack long-term efficacy 3
• Approximately 70% of OME episodes resolve spontaneously within 3 months 3
• Offer bilateral tympanostomy tube insertion for chronic OME (≥3 months) with mild hearing loss (16-40 dB HL) and bilateral effusions 1
• Monitor every 3-6 months for resolution, hearing loss development, and structural abnormalities 1, 3

For Tympanic Membrane Perforation:

• Use only non-ototoxic topical antibiotic preparations when antibiotic therapy is indicated 3
• Never use ototoxic topical antibiotics (aminoglycosides) if any possibility of perforation exists - risk of permanent sensorineural hearing loss 3
• Avoid irrigation in patients with perforation or patent tympanostomy tubes - risk of suppurative otitis media, caloric vertigo, and ototoxicity 1

For Blood on Tympanic Membrane (Granulation Tissue):

• Topical quinolone drops with or without dexamethasone is the treatment of choice for granulation tissue at tympanostomy tube sites 5
• Do not prescribe systemic antibiotics for this condition 5

For Structural Abnormalities:

• Posterosuperior retraction pockets, ossicular erosion, and adhesive atelectasis may benefit from tympanostomy tube insertion regardless of OME duration 1
• All children with these conditions should have audiologic evaluation 1

Special Considerations

High-risk populations requiring closer monitoring:

• Children with developmental disabilities, learning disorders, or ADHD should be evaluated for OME at diagnosis of the at-risk condition and at 12-18 months of age 3
• Diabetic patients undergoing ear irrigation have higher risk of malignant otitis externa 1
• Patients with history of ear surgery, tympanic membrane perforation, or tympanostomy tubes require manual cerumen removal rather than irrigation 1