Management of Bullous Myringitis in a 47-Year-Old Male
Treat this patient with high-dose amoxicillin (80–90 mg/kg/day divided twice daily) and provide immediate pain control with ibuprofen or acetaminophen. 1
Understanding the Clinical Presentation
This patient has bullous myringitis (also called hemorrhagic myringitis), which is a specific and often excessively painful variant of acute otitis media characterized by fluid-filled bullae on the tympanic membrane. 2 The combination of ear pain, erythema, and central bullous lesions on the tympanic membrane meets diagnostic criteria for acute otitis media with middle-ear effusion and inflammation. 3
Bullous myringitis is not a separate disease entity—it represents a particularly severe manifestation of acute otitis media caused by the same bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2 The presence of bullae indicates significant middle-ear inflammation and warrants the same antibiotic treatment as standard AOM. 2
First-Line Antibiotic Therapy
High-dose amoxicillin (80–90 mg/kg/day) is the first-line antibiotic because it overcomes intermediate penicillin resistance in S. pneumoniae and achieves superior middle-ear penetration. 1
The bulging/bullous appearance of the tympanic membrane is one of the most specific signs of bacterial middle-ear infection and indicates moderate-to-severe disease requiring immediate antibiotic therapy. 1
Do not observe without antibiotics in this case—the presence of a bulging or bullous tympanic membrane precludes watchful waiting, even in adults. 1
Pain Management (Critical Priority)
Prescribe ibuprofen or acetaminophen immediately and initiate within the first 24 hours, regardless of antibiotic use. 3, 1
Bullous myringitis is notably more painful than typical AOM, and aggressive pain control is essential for quality of life. 2
Special Considerations for Bullous Myringitis
Consider myringotomy (incision and drainage of the bullae) if pain is severe or refractory to medical management—this can provide immediate symptomatic relief and may be a medical emergency in cases of excessive pain. 2
Monitor for sensorineural hearing loss, which can occur in approximately 14% of bullous myringitis cases (3 of 22 patients in one series) and is usually reversible with treatment. 4
The bullae typically contain hemorrhagic fluid, distinguishing this from simple middle-ear effusion. 2, 4
Follow-Up and Reassessment
Reassess at 48–72 hours if symptoms persist or worsen—this may indicate beta-lactamase-producing organisms requiring amoxicillin-clavulanate. 1
Refer urgently to otolaryngology if the patient develops mastoid tenderness, as this suggests progression to acute mastoiditis requiring CT imaging and possible surgical intervention. 1
If sensorineural hearing loss is suspected (patient reports muffled hearing beyond conductive loss), consider systemic corticosteroids and obtain formal audiometry. 2
Common Pitfalls to Avoid
Do not confuse bullous myringitis with otitis media with effusion (OME)—OME lacks acute inflammatory signs and pain, and does not require antibiotics. 3, 5
Do not rely on tympanic membrane redness alone for diagnosis, as erythema has poor predictive value and can result from non-infectious causes. 3
Do not use topical antibiotics when the tympanic membrane is intact, as they cannot reach the middle ear. 1
Do not attribute bullous myringitis to Mycoplasma pneumoniae—despite historical teaching, complement fixation studies have failed to implicate M. pneumoniae, influenza, or adenovirus as causative agents. 4 The responsible pathogens are the same as in standard AOM. 2
Alternative Antibiotic if Amoxicillin Fails
- If no improvement occurs after 48–72 hours, switch to amoxicillin-clavulanate to cover beta-lactamase-producing strains of H. influenzae and M. catarrhalis. 1