Management of Bullous Myringitis
Bullous myringitis should be treated as a severe variant of acute otitis media with the same antibiotics (targeting S. pneumoniae, H. influenzae, M. catarrhalis), combined with aggressive pain management, and in cases with severe pain or sensorineural hearing loss, consider myringotomy to drain hemorrhagic bullae plus systemic corticosteroids. 1
Initial Assessment and Recognition
Bullous myringitis is a rare but particularly severe manifestation of acute otitis media, accounting for approximately 8% of AOM cases. 2 The key distinguishing features include:
- Hemorrhagic bullae on the tympanic membrane and medial external auditory canal wall 1, 3
- More severe pain than typical AOM, with sudden onset of severe otalgia 2, 4
- Higher symptom severity including more frequent earache (58%), fever ≥38°C (62%), restless sleeping, excessive crying, and poor appetite compared to standard AOM 4
- Bulging of tympanic membrane in quadrants not obscured by bullae 2
Critical pitfall: In children under 2 years, symptoms may be less specific—look for excessive crying, ear rubbing, and restless sleep rather than relying on verbal complaints of pain. 4
Immediate Management Priorities
Pain Control
Aggressive pain management is essential and non-negotiable. 2 Children with bullous myringitis are not appropriate candidates for watchful waiting due to the severity of symptoms—parents will resist postponement of treatment when children are highly symptomatic. 2
Antibiotic Therapy
Treat with the same antibiotics used for acute otitis media, targeting the identical pathogens: S. pneumoniae (which shows relative increase in bullous myringitis), H. influenzae, and M. catarrhalis. 1, 2 The choice of antibiotic should be adapted to each clinical situation following standard AOM guidelines. 1
Surgical Intervention
Consider myringotomy with drainage of hemorrhagic bullae in cases presenting as a medical emergency, particularly when: 1
- Pain is excessively severe
- Sensorineural hearing loss is present or suspected
- Symptoms are not rapidly improving with medical management
Monitoring for Complications
Sensorineural Hearing Loss
This is a more common complication than historically recognized and requires vigilant monitoring:
- Occurs in 13-65% of cases depending on the study 3, 5
- Usually temporary and reversible in the majority of cases (complete recovery in 8 of 13 ears in one series) 5
- Cochlear origin suggested by stapedial reflex testing showing recruitment 5
- Perform audiometry if hearing loss is suspected, particularly in older children and adults 3, 5
Systemic Corticosteroids
Administer systemic corticosteroids when sensorineural hearing loss develops or in cases requiring emergency management. 1 This represents a key difference from standard AOM management.
Clinical Course and Follow-Up
- Symptoms typically resolve in 1-2 days in the majority of cases 4
- Middle ear fluid develops in 97% of cases during the disease course 4
- Short-term outcome is generally good despite initial severity 4
- The condition occurs mainly in older children (median age 4.3 years vs 18 months for standard AOM) and young adults 2, 3
- Winter predominance with preceding or concurrent upper respiratory infection in most cases 3
Key Clinical Pearls
Age consideration: Bullous myringitis affects significantly older children than typical AOM, so maintain high suspicion in preschool and school-age children presenting with severe otalgia. 2
Tympanostomy tubes: No cases of bullous myringitis occur in ears with patent tympanostomy tubes, suggesting middle ear pressure plays a role in pathogenesis. 4
Viral studies: Despite historical association with Mycoplasma pneumoniae and influenza, complement fixation studies have failed to consistently implicate these or other viral pathogens. 3