What is the differential diagnosis for an adult patient with no significant medical history presenting with bleeding from the ear?

Differential Diagnosis for Bleeding from the Ear

Traumatic Causes

Temporal bone fracture with vascular injury is the most critical diagnosis to exclude in any adult presenting with ear bleeding, particularly when associated with head trauma. 1, 2

Skull Base and Temporal Bone Injuries

• Longitudinal petrosal bone fractures can cause bleeding from the middle meningeal artery or other vascular structures, presenting as intractable ear bleeding that may require endovascular embolization rather than conservative management 1
• Basilar skull fractures classically present with hemorrhagic otorrhea and should be suspected with any significant head trauma 2
• Facial trauma can produce bilateral hemorrhagic otorrhea even without obvious skull base fracture, representing an important but often missed differential 2

External Ear Trauma

• Auricular hematoma can occur spontaneously without antecedent trauma, presenting as acute painful swelling requiring urgent incision and drainage if large 3
• Direct trauma to the external auditory canal from cotton swabs, hearing aids, or other foreign objects can cause bleeding, particularly in patients with coagulopathies 4

Infectious and Inflammatory Causes

Acute Otitis Externa

• Otitis externa presents with ear canal inflammation, tenderness with tragal pressure, edema, erythema, and discharge that may be bloody, caused primarily by Pseudomonas aeruginosa (20-60% of cases) and Staphylococcus aureus 5, 6
• Bleeding occurs when inflamed, friable canal tissue is manipulated or when aggressive irrigation is performed 4

Necrotizing (Malignant) Otitis Externa

• Skull base osteomyelitis can erode into the internal carotid artery, creating a pseudoaneurysm that presents with recurrent ear bleeding—this is a life-threatening emergency requiring urgent angiography and endovascular intervention 7
• High-risk patients include elderly individuals with diabetes, immunocompromised states (HIV/AIDS, chemotherapy, organ transplant), or prior head and neck radiation 4, 7
• Persistent ear pain with cranial nerve symptoms and recurrent bleeding should trigger immediate imaging and ENT consultation 7

Acute Otitis Media with Perforation

• Spontaneous tympanic membrane perforation from acute otitis media can cause bloody otorrhea, typically accompanied by acute ear pain that suddenly improves when perforation occurs 4, 6
• The tympanic membrane appears erythematous and bulging before rupture, with common bacterial pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 6

Chronic Suppurative Otitis Media

• CSOM is defined as chronic middle ear inflammation with persistent ear discharge through a non-intact tympanic membrane, which may be bloody when granulation tissue or cholesteatoma is present 4

Vascular Causes

Internal Carotid Artery Pseudoaneurysm

• ICA pseudoaneurysm can present with epistaxis and ear hemorrhage as the first manifestation, requiring emergency CT angiography and coil embolization to prevent fatal hemorrhage 8, 7
• This rare complication occurs secondary to skull base osteomyelitis with invasion of the petrous ICA wall, or following trauma 8, 7
• Recurrent bleeding despite initial intervention may require repeat embolization with stent deployment 7

Neoplastic Causes

Ear Canal and Middle Ear Tumors

• Malignancies of the external auditory canal can present with bloody discharge, particularly squamous cell carcinoma or adenoid cystic carcinoma
• Upper aerodigestive tract cancers can cause referred otalgia with bleeding, especially in high-risk patients (tobacco/alcohol use, age >50, diabetes) 6

Iatrogenic and Procedural Causes

Cerumen Removal Complications

• Ear canal abrasion during cerumen removal is more likely in patients with coagulopathies (antiplatelet therapy, anticoagulation, hepatic/renal failure, thrombocytopenia, hemophilia) who require special counseling about bleeding risk 4
• Irrigation-related trauma can occur, particularly in immunocompromised or diabetic patients where aggressive irrigation has been implicated in triggering necrotizing otitis externa 4
• Prior head and neck radiation causes epithelial thinning and atrophy, making the ear canal more susceptible to injury and slow healing with risk of osteoradionecrosis 4

Systemic Causes

Coagulopathies

• Bleeding disorders including anticoagulant medications, antiplatelet therapy, hepatic failure, renal failure, thrombocytopenia, and hemophilia increase risk of spontaneous or minor trauma-related ear bleeding 4

Critical Red Flags Requiring Urgent Evaluation

• Recurrent or persistent bleeding despite conservative management suggests vascular injury requiring angiography 7, 1
• Cranial nerve symptoms with ear bleeding indicate possible skull base involvement or ICA pseudoaneurysm 7
• Diabetes or immunocompromised state with ear bleeding and pain warrants aggressive evaluation for necrotizing otitis externa 4, 7
• History of head trauma with ear bleeding requires imaging to exclude temporal bone fracture and epidural hematoma 1, 2
• Bilateral hemorrhagic otorrhea should prompt evaluation for both skull base fracture and facial trauma 2

Initial Diagnostic Approach

• Otoscopic examination to visualize the tympanic membrane, identify canal trauma, assess for foreign bodies, and evaluate for signs of infection or tumor 4
• Pneumatic otoscopy to assess tympanic membrane mobility and distinguish otitis media with effusion from acute infection 4
• CT temporal bones for suspected fracture, skull base osteomyelitis, or when bleeding is severe or recurrent 8, 7, 1
• CT angiography urgently if vascular injury or pseudoaneurysm is suspected based on persistent bleeding or high-risk features 8, 7
• Coagulation studies in patients with risk factors for bleeding disorders 4