Bullous myringitis is a direct inflammation and infection of the TM secondary to a viral or bacterial agent. The hallmarks of bullous myringitis are vesicles or bullae filled with blood or serosanguinous fluid on an erythematous TM. Frequently, a concomitant OM with effusion is noted. Typical pathogens are the same as seen in AOM.
The onset of bullous myringitis is preceded by an upper respiratory tract infection and is heralded by sudden onset of severe ear pain, scant serosanguinous drainage from the ear canal, and frequently some degree of hearing loss. Otoscopy reveals bullae on either the inner or outer surface of the TM. Patients presenting with fever, hearing loss, and purulent drainage are more likely to have concomitant infections, such as OM and otitis externa.
Management and Disposition
Differentiation between viral and bacterial etiologies for TM bullae is not necessary. Although most episodes have a viral etiology and resolve spontaneously, many physicians prescribe antibiotics to cover presumptive Mycoplasma pneumoniae. Warm compresses, topical or strong analgesics, and oral decongestants provide symptomatic relief. Referral is not necessary in most cases unless rupture of the bullae is required for pain relief.
Instruct parents that TM rupture may occur with sudden resolution of the pain and drainage from the ear canal.
Carefully differentiate TM bullae from cholesteatomas or herpetic vesicles.
Facial nerve paralysis associated with clear, fluid-filled TM vesicles is characteristic of herpes zoster oticus.
Bullous Myringitis. A large fluid-filled bulla is seen distorting the surface of the tympanic membrane. (Photo contributor: Michael Hawke, MD, and The Hawke Library.)
Video 05-06: Bullous Myringitis
Note the bullae on the superior aspect of the TM in this 11 year old with fever and ear pain. (Video Contributor: Kevin J. Knoop, MD, MS)