What is the best course of action for a patient with hearing loss, no pain, and pulsatile tinnitus (hearing their heartbeat in the ear) after ear flushing, with dried blood on the tympanic membrane?

Urgent Otolaryngology Referral for Suspected Tympanic Membrane Perforation

This patient requires immediate otolaryngology evaluation for suspected tympanic membrane perforation with possible sudden sensorineural hearing loss, and ear irrigation should be avoided until the tympanic membrane integrity is confirmed. 1

Immediate Clinical Concerns

The combination of dried blood on the tympanic membrane following ear irrigation, new hearing loss, and pulsatile tinnitus raises critical red flags:

• Dried blood on the tympanic membrane strongly suggests traumatic perforation from the irrigation procedure 2, 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends avoiding ear irrigation when the tympanic membrane status is uncertain or when blood suggests possible perforation 1
• Pulsatile tinnitus in this context may indicate middle ear pathology or exposure of vascular structures through a perforation 3, 4

Critical Diagnostic Steps Required

Distinguish Conductive vs. Sensorineural Hearing Loss

Perform Weber and Rinne tuning fork tests immediately to differentiate the type of hearing loss, as this fundamentally changes management strategy: 2, 1

• Weber test lateralizing to the affected ear suggests conductive hearing loss from perforation/blood in middle ear 2
• Rinne test showing bone conduction better than air conduction confirms conductive pathology 2
• If tests suggest sensorineural component, this becomes a medical emergency requiring corticosteroid therapy 1

Obtain Formal Audiometry Urgently

The American Academy of Otolaryngology-Head and Neck Surgery recommends obtaining formal audiometry within 24-48 hours to confirm the type and degree of hearing loss 1

• Sudden sensorineural hearing loss is defined as ≥30 dB loss over at least 3 contiguous frequencies occurring within 72 hours 1
• Patients with sensorineural hearing loss cannot be accurately distinguished by symptoms alone and require objective testing 2

Management Algorithm

If Conductive Hearing Loss is Confirmed (Most Likely Scenario)

The presence of dried blood and recent trauma from irrigation strongly suggests conductive pathology from tympanic membrane perforation with possible hemotympanum: 2

• Refer to otolaryngology for microscopic examination to assess perforation size and location 2
• Most traumatic perforations heal spontaneously within 2-3 months with conservative management 2
• Keep the ear dry and avoid ototoxic drops until tympanic membrane integrity is confirmed 1
• The pulsatile tinnitus will likely resolve as the perforation heals and middle ear blood clears 3, 4

If Sensorineural Component is Present (Time-Critical Emergency)

The American Academy of Otolaryngology-Head and Neck Surgery recommends initiating corticosteroid therapy as soon as possible for sensorineural hearing loss, as outcomes are time-dependent: 1

• Oral prednisone 1 mg/kg/day (max 60 mg) for 7-14 days should be started immediately 1
• Earlier treatment within 2 weeks is associated with better outcomes 1
• This patient is already one week post-injury, making urgent treatment critical 1

Key Clinical Pitfalls to Avoid

Never use ototoxic ear drops when tympanic membrane perforation is suspected, as the American Academy of Otolaryngology-Head and Neck Surgery advises against using ototoxic drops until the tympanic membrane is confirmed to be completely intact: 1

Do not assume the hearing loss is purely conductive without objective testing—patients cannot accurately distinguish subjective hearing loss as either conductive or sensorineural: 2

Do not delay referral waiting for "spontaneous improvement"—if there is any sensorineural component, every day of delay worsens prognosis: 1

Pulsatile Tinnitus Considerations

The pulsatile tinnitus in this context most likely represents:

• Transmission of vascular sounds through a perforated tympanic membrane or blood-filled middle ear space 3, 4
• This should resolve as the perforation heals and middle ear clears 3
• Persistent pulsatile tinnitus after healing would warrant vascular imaging to exclude aberrant internal carotid artery or other vascular anomalies 3, 4