Most Common Pathogen in Myringitis Bullosa
The most common pathogens in bullous myringitis are identical to those causing acute otitis media: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis, with S. pneumoniae showing a relative increase in proportion compared to standard acute otitis media. 1, 2
Bacterial Etiology
Bullous myringitis (also called hemorrhagic myringitis) represents a rare and particularly painful manifestation of acute otitis media rather than a distinct disease entity. 1 The causative organisms mirror those of standard AOM:
Streptococcus pneumoniae is the most frequently identified pathogen, with studies showing a relative increase in its proportion in bullous myringitis compared to AOM without bullae. 1, 2
Nontypeable Haemophilus influenzae remains a major pathogen, particularly in the post-PCV7 vaccination era where it rivals S. pneumoniae as the most common bacterial cause. 3, 1
Moraxella catarrhalis accounts for a smaller but significant proportion of cases, with the majority of strains producing beta-lactamase. 3, 1
Key Clinical Distinctions
Bullous myringitis accounts for approximately 7.9% of all AOM cases and presents with more severe symptoms than standard AOM. 2 Children with bullous myringitis are typically older (median age 4.3 years versus 18 months for standard AOM) and experience significantly more pain at diagnosis. 2
The hemorrhagic bullae on the tympanic membrane and medial external auditory canal wall can cause moderately severe otalgia and, in rare cases, reversible sensorineural hearing loss. 1, 4
Common Pitfall: The Mycoplasma Myth
Contrary to historical teaching, Mycoplasma pneumoniae is NOT a common cause of bullous myringitis. 5 Earlier studies overestimated the incidence of M. pneumoniae in bullous myringitis due to non-specific diagnostic tests. 5 Modern complement fixation antibody studies have failed to implicate M. pneumoniae, influenza viruses, or adenovirus as causal agents. 4
Treatment Implications
Treat bullous myringitis identically to acute otitis media, using the same antibiotic selection based on the three primary bacterial pathogens. 1 However, recognize that:
Children with bullous myringitis require aggressive pain management due to more severe symptoms. 2
These patients are poor candidates for watchful waiting approaches, as parents typically resist postponement of antibiotic therapy when children are highly symptomatic. 2
Management may constitute a medical emergency requiring opening of hemorrhagic bullae and systemic corticosteroid therapy in severe cases. 1