How should I manage ear bleeding?

Management of Ear Bleeding

Stop any ear manipulation immediately, apply gentle external pressure if bleeding is from the outer ear, and seek prompt medical evaluation to determine the source and severity of bleeding. 1

Immediate Assessment and Actions

Determine the Source and Severity

You must first identify whether this is:

• External ear bleeding (from trauma, laceration, or auricular hematoma) 2, 3
• Ear canal bleeding (from chemical irritation, trauma, or infection) 1
• Middle ear bleeding (appearing as bloody drainage through a perforation or tympanostomy tube) 4

Critical Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if any of the following are present:

• Hemodynamic instability or signs of significant blood loss 4
• Persistent or worsening bleeding despite local measures 1
• Associated hearing loss or feeling of fullness 1
• Fever or signs of systemic illness 1
• History of anticoagulant use (warfarin, DOACs, or antiplatelet agents) 4

Initial Management Based on Source

For External Ear Bleeding (Trauma/Laceration)

Apply direct pressure with clean gauze to control active bleeding from lacerations or abrasions 5

• Use manual compression as the first-line intervention for external bleeding 4
• Assess for auricular hematoma (fluctuant swelling within the cartilaginous auricle), which requires evacuation within 7 days of injury to prevent cauliflower ear deformity 3
• If hematoma is present, drainage via needle aspiration or incision and drainage followed by bolster compression dressing is indicated 3

For Ear Canal or Middle Ear Bleeding

Do not insert anything into the ear canal to investigate or clean, as this can cause further injury 1

• If bleeding follows hydrogen peroxide use or chemical irritation, discontinue immediately and seek evaluation for possible tympanic membrane perforation or acute otitis externa 1
• Pink or bloody drainage in children with tympanostomy tubes is usually from granulation tissue and should be treated with topical quinolone drops (with or without dexamethasone); reassure that this is not concerning and does not require systemic antibiotics 4
• Avoid irrigation or cerumen-removing drops if tympanic membrane perforation is suspected, as this can cause infection or vertigo 6

Pain Management

Administer oral analgesics at fixed intervals rather than as-needed for better pain control 1

• NSAIDs (ibuprofen) are particularly effective during acute ear canal inflammation 1
• Acetaminophen is an alternative for patients who cannot take NSAIDs 1

Special Considerations for Anticoagulated Patients

If the patient is on oral anticoagulants (warfarin, DOACs, or antiplatelet agents):

• Stop anticoagulation if bleeding is significant 4
• Provide local therapy and manual compression as first-line measures 4
• For vitamin K antagonists (warfarin): give 2-5 mg oral or IV vitamin K for non-major bleeds, or 5-10 mg IV for major bleeds 4
• Assess for comorbidities that contribute to bleeding (thrombocytopenia, uremia, liver disease) 4

What NOT to Do

Critical pitfalls to avoid:

• Never use ear candles or unproven remedies, as these cause serious additional damage 1
• Do not attempt home irrigation or further cleaning after bleeding, as this can worsen injury or push debris deeper 1
• Avoid hydrogen peroxide instillation into the ear canal unless specifically directed by an otolaryngologist, and never use if tympanic membrane perforation or tubes are present 1, 6
• Do not assume bleeding will resolve on its own—ear bleeding requires professional evaluation to prevent complications 1

When to Refer to Otolaryngology

Refer promptly for:

• Auricular hematoma requiring drainage and compression dressing 3
• Persistent bleeding despite initial measures 1
• Suspected tympanic membrane perforation requiring otoscopic examination 1, 6
• Complex lacerations requiring meticulous repair to prevent infection or tissue loss 5
• Signs of perichondritis (the most feared complication of ear trauma, requiring aggressive management) 5

Follow-up Care

• Patients with auricular hematoma drainage should be reevaluated at 24-48 hours and abstain from contact sports for at least 2 weeks 3
• Consider 7-10 days of antibiotics with Pseudomonas coverage (fluoroquinolones in adults, amoxicillin-clavulanate in children) after hematoma drainage to mitigate perichondritis risk 3
• For bloody otorrhea with tympanostomy tubes, topical quinolone therapy typically resolves the issue without need for tube removal 4