Bullous Myringitis
Based on the clinical presentation of severe ear pain following an upper respiratory infection, with otoscopic findings of fluid-filled vesicles on an erythematous tympanic membrane, the most likely diagnosis is bullous myringitis.
Clinical Presentation and Diagnostic Features
Bullous myringitis presents with moderately severe to severe otalgia associated with characteristic vesicles (bullae) on the tympanic membrane and medial external auditory canal wall. 1 The condition occurs predominantly in young adults, most commonly during winter months, and is typically preceded or accompanied by an upper respiratory infection 1—exactly matching this patient's presentation.
Key Distinguishing Features
- Vesicles or bullae on the tympanic membrane are the pathognomonic finding that differentiates bullous myringitis from other ear pathology 1, 2
- The tympanic membrane appears erythematous with fluid-filled vesicles, creating a distinctive appearance 3
- Severe ear pain is characteristic, often more intense than typical acute otitis media 2, 3
- Hearing loss can occur, with reversible sensorineural hearing loss developing in approximately 14% of cases 1
Association with Middle Ear Disease
Bullous myringitis is commonly associated with acute inflammation of the middle ear cleft. 2 In children under 2 years, middle ear disease is present in 97% of ears with bullous myringitis 4, though this patient's adult age makes isolated tympanic membrane involvement more likely. The bacterial pathogen distribution mirrors acute otitis media, with Streptococcus pneumoniae being the predominant organism 4.
Differential Diagnosis Considerations
Why Not the Other Options?
Otitis externa (d) presents with tragal tenderness, ear canal edema, and erythema but does not produce vesicles on the tympanic membrane 5, 6
Ramsay Hunt syndrome (e) would require vesicles on the external ear, pinna, or periauricular skin along with facial nerve paresis 6. This patient has no tinnitus, no facial weakness, and the vesicles are specifically on the tympanic membrane—not the external structures 6
Cholesteatoma (b) is a chronic condition presenting with retraction pockets, ossicular erosion, or pearly white debris behind the tympanic membrane 7—not acute severe pain with vesicles
Granulomatosis with polyangiitis (c) would present with systemic symptoms, chronic rhinosinusitis, and destructive upper airway lesions—not isolated acute ear pain with vesicles
Management Approach
Children and adults with bullous myringitis require aggressive pain management due to the severity of symptoms. 3 The condition should be treated similarly to acute otitis media when middle ear involvement is present 4:
- Analgesics are essential, including NSAIDs or acetaminophen for the severe otalgia 6
- Antibiotic therapy may be warranted given the high association with bacterial middle ear infection, particularly S. pneumoniae 4
- Watchful waiting is generally not appropriate for bullous myringitis due to the severity of pain, even in older children or adults who might otherwise be candidates for observation 3
Clinical Pitfalls to Avoid
- Do not dismiss vesicles on the tympanic membrane as simple acute otitis media—the presence of bullae defines a specific entity requiring more aggressive pain control 3
- Do not confuse bullous myringitis with Ramsay Hunt syndrome—the latter requires external ear vesicles and facial nerve involvement, not isolated tympanic membrane findings 6
- Do not assume viral etiology alone—bacterial pathogens, especially S. pneumoniae, are commonly present and may warrant antibiotic therapy 4