Treatment of Bullous Otitis (Bullous Myringitis)
Bullous otitis (bullous myringitis) should be treated identically to acute otitis media with systemic antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, combined with aggressive pain management and consideration for myringotomy to drain hemorrhagic bullae in severe cases. 1
Understanding Bullous Otitis
Bullous myringitis is not a separate disease entity but rather a rare and particularly painful manifestation of acute otitis media characterized by hemorrhagic bullae on the tympanic membrane. 1 The causative organisms are identical to those in standard acute otitis media: S. pneumoniae, H. influenzae, and M. catarrhalis. 1
First-Line Antibiotic Treatment
For Children Over 3 Months of Age
Amoxicillin remains the first-line antibiotic at high doses (90 mg/kg/day) in communities where beta-lactamase-producing strains are infrequent. 2, 3, 4, 5
For children who received antibiotics in the previous 4-6 weeks or in areas with resistant organisms, use amoxicillin-clavulanate (90 mg/6.4 mg per kg per day), cefpodoxime proxetil, cefuroxime axetil, or cefdinir as initial therapy. 2
Treatment duration should be 8-10 days for children under 2 years and 5 days for older children. 2
For Patients with Beta-Lactam Allergies
- Erythromycin-sulfisoxazole is an alternative for patients with beta-lactam allergies, though bacterial failure rates of 20-25% are possible. 2, 3
Critical Pain Management
Pain control is paramount in bullous myringitis as it can be excessively painful. 1
Prescribe analgesics based on pain severity, starting with acetaminophen or NSAIDs for mild-to-moderate pain. 2, 6
Pain typically improves within 48-72 hours of initiating appropriate therapy. 2, 6
Surgical Intervention for Severe Cases
Myringotomy (opening of hemorrhagic bullae) may be a medical emergency in bullous myringitis to provide immediate pain relief and prevent sensorineural hearing loss. 1 This is particularly indicated when:
- Pain is severe and unresponsive to analgesics 1
- There is concern for complications 1
- Bacteriological evaluation is needed in infants under 6 months, immunocompromised patients, or treatment failures 3
Systemic Corticosteroids
Consider systemic corticosteroids in severe cases of bullous myringitis to reduce inflammation and prevent sensorineural hearing loss, which is a recognized complication. 1 However, the evidence for routine corticosteroid use in acute otitis media is limited. 2
Reassessment and Treatment Failure
Reassess patients within 48-72 hours if symptoms are not improving or are worsening. 2
Treatment failure is defined as worsening condition, persistence of symptoms beyond 48 hours, or recurrence within 4 days of treatment discontinuation. 2
For treatment failures, perform myringotomy with bacteriological specimen collection to guide antibiotic selection, particularly in infants under 6 months and immunocompromised patients. 2, 3
Common Pitfalls to Avoid
Do not confuse bullous myringitis with acute otitis externa. Bullous myringitis involves the tympanic membrane and middle ear, requiring systemic antibiotics, whereas otitis externa is treated primarily with topical therapy. 2, 6
Do not use topical ear drops alone for bullous myringitis, as this is a manifestation of acute otitis media requiring systemic antibiotics. 1
Do not delay myringotomy in severe cases, as the hemorrhagic bullae can cause significant pain and potential hearing complications. 1
Avoid prescribing antibiotics for isolated tympanic membrane redness without other signs of acute otitis media, as this does not warrant treatment. 2