What is the appropriate management for hemotympanum (middle‑ear hemorrhage)?

Management of Hemotympanum (Middle Ear Hemorrhage)

Hemotympanum should be managed conservatively with observation, antibiotics, decongestants, and correction of any underlying coagulopathy, as spontaneous resolution typically occurs within 1-4 weeks without surgical intervention.

Immediate Assessment

Identify the Underlying Cause

• Evaluate for anticoagulant use (warfarin, enoxaparin, direct oral anticoagulants) as this is a critical reversible cause of spontaneous hemotympanum 1, 2
• Assess for head trauma or temporal bone fracture through history and physical examination, as blunt trauma is the most common etiology 3, 4
• Check for bleeding disorders including thrombocytopenia, as immune thrombocytopenic purpura can present with hemotympanum and hearing loss 5
• Consider barotrauma from diving or air travel as a precipitating factor 4

Obtain Coagulation Studies

• Order a complete coagulation profile including prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen level, and platelet count to identify coagulopathy 6
• This is essential before determining management strategy, particularly if anticoagulation reversal is needed 7, 6

Conservative Management (First-Line Approach)

Medical Treatment

• Prescribe a 10-14 day course of prophylactic antibiotics (such as amoxicillin-clavulanate) to prevent secondary infection 1, 5
• Add nasal decongestants to promote Eustachian tube drainage 1
• Provide analgesics for otalgia as needed 1, 4

Anticoagulation Management

• Temporarily interrupt anticoagulant therapy in consultation with the prescribing physician if hemotympanum is anticoagulant-related 1
• For elevated INR (warfarin use), administer prothrombin complex concentrate at doses of 25-50 U/kg depending on INR level, plus intravenous vitamin K 5-10 mg 7, 6
• For thrombocytopenia, consider high-dose corticosteroids (methylprednisolone) if platelet count is critically low with active bleeding 5

Monitoring Protocol

• Perform serial otoscopic examinations every 1-2 weeks to document resolution 1, 4
• Obtain baseline and follow-up audiometry to assess for conductive hearing loss, though most cases show minimal hearing impairment 4
• Watch for complications including persistent conductive hearing loss, chronic otitis media, or signs of temporal bone fracture 3

When Imaging Is Indicated

CT Temporal Bone

• Order CT only if trauma is suspected or if clinical examination suggests temporal bone fracture 3
• CT is NOT routinely needed for spontaneous hemotympanum without trauma history 7, 1
• Imaging helps exclude middle ear cavity bleeding, temporal bone fracture, and intracranial complications 3, 4

Expected Outcomes and Follow-Up

Resolution Timeline

• Most cases resolve spontaneously within 3-4 weeks with conservative management 1, 4
• Hearing typically returns to baseline once blood resorbs from the middle ear 1, 5
• Tympanic membranes return to normal appearance without surgical intervention 1, 5

Thromboprophylaxis Considerations

• Restart anticoagulation as soon as bleeding is controlled to prevent thromboembolic complications, particularly in patients with mechanical heart valves or high thrombotic risk 6
• The prothrombotic state develops rapidly after hemorrhage cessation 7

Key Clinical Pitfalls to Avoid

• Do not assume trauma is the only cause—always investigate for anticoagulant use and bleeding disorders, as these are increasingly common etiologies 1, 2
• Do not rush to surgical intervention—hemotympanum resolves conservatively in the vast majority of cases 1, 4
• Do not overlook the need for prophylactic antibiotics—secondary infection can complicate an otherwise benign condition 1, 5
• Do not forget to restart anticoagulation—prolonged interruption increases thrombotic risk in high-risk patients 6