What is the management plan for a patient with dried blood in the left ear canal, intact tympanic membrane (TM), and sudden loss of hearing in the left ear, without vertigo or dizziness?

Management of Dried Blood in Ear Canal with Intact TM and Sudden Hearing Loss

This patient requires urgent audiometric evaluation and consideration of corticosteroid therapy for sudden sensorineural hearing loss (SSNHL), as the intact tympanic membrane with hearing loss suggests inner ear pathology rather than middle ear trauma. 1

Immediate Diagnostic Steps

Distinguish Conductive vs Sensorineural Hearing Loss

• Perform Weber and Rinne tuning fork tests to differentiate the type of hearing loss, as this fundamentally changes management strategy 1

  • Weber test: Place 512 Hz tuning fork at midline; lateralization to affected ear suggests conductive loss, to opposite ear suggests sensorineural loss 1
  • Rinne test: Compare bone vs air conduction; air conduction better than bone is normal, reversed suggests conductive loss 1

• Obtain formal audiometry urgently (within 24-48 hours) to confirm SSNHL and establish baseline 1

  • SSNHL is defined as ≥30 dB hearing loss over at least 3 contiguous frequencies occurring within 72 hours 1

Examine for Source of Blood

• Gently remove dried blood with suction or dry mopping under direct visualization to fully assess the ear canal and tympanic membrane 1

  • Avoid irrigation if TM integrity is uncertain 1
  • Use otoscope with open head or binocular microscope for adequate visualization 1

• Carefully inspect the entire TM to confirm it is truly intact, as small perforations can be missed 1, 2

  • Blood in canal with intact TM suggests either external canal trauma or hemorrhagic otitis media 2

Treatment Algorithm Based on Hearing Loss Type

If Sensorineural Hearing Loss Confirmed (Most Likely Given Clinical Picture)

Initiate corticosteroid therapy as soon as possible, as outcomes are time-dependent 1:

• Oral corticosteroids are the first-line treatment option:

  • Typical regimen: Prednisone 1 mg/kg/day (max 60 mg) for 7-14 days with or without taper 1
  • Earlier treatment (within 2 weeks) associated with better outcomes 1

• Consider intratympanic steroids as salvage therapy if incomplete recovery after initial oral therapy, or as primary therapy if oral steroids contraindicated 1

• Obtain MRI of internal auditory canals to rule out vestibular schwannoma or other retrocochlear pathology 1

  • Can be deferred if not immediately available, but should be obtained within weeks to months 1
  • Alternative: ABR testing as less sensitive screening tool, though abnormal ABR requires MRI 1

If Conductive Hearing Loss Confirmed

• Reassess TM integrity more carefully, as conductive loss with "intact" TM is uncommon 1

  • Consider tympanometry to confirm intact TM (Type A tracing indicates intact membrane) 1
  • Remove all cerumen/debris that might obscure small perforation 1

• If truly intact TM with conductive loss, consider ossicular chain disruption from temporal bone trauma 1, 2

  • Refer to otolaryngology for specialized evaluation 1

Key Management Principles

Ear Canal Care

• Keep ear dry until source of bleeding identified and hearing loss etiology determined 2
• Avoid ototoxic drops since TM integrity must be absolutely confirmed before using aminoglycoside-containing preparations 1
• Do not irrigate the ear canal given history of blood and hearing loss 1

Follow-Up Requirements

• Repeat audiometry within 6 months of SSNHL diagnosis to document final hearing outcome 1
• Otolaryngology referral is warranted for:
  • Confirmed SSNHL requiring specialized management 1
  • Conductive hearing loss >30 dB suggesting ossicular injury 1, 2
  • Persistent blood or unclear source of hemorrhage 3

Critical Pitfalls to Avoid

• Do not assume conductive loss without objective testing; patients cannot reliably distinguish subjective hearing loss type 1
• Do not delay steroid therapy if SSNHL suspected, as spontaneous recovery occurs in only one-third to two-thirds of cases, and earlier treatment improves outcomes 1
• Do not use ear irrigation when TM status is uncertain or when blood suggests possible perforation 1
• Do not prescribe ototoxic topical antibiotics (aminoglycosides, polymyxin) until TM confirmed completely intact 1

Prognosis Considerations

• Patients recovering ≥50% of hearing within first 2 weeks have better overall prognosis 1
• Presence of vertigo at onset indicates poorer prognosis for hearing recovery 1
• Minimal improvement within 2 weeks suggests unlikely significant spontaneous recovery 1