Haemotympanum

Haemotympanum is blood in the middle ear cavity, seen as a blue or dark red drum. It results from trauma, barotrauma, infection or a bleeding disorder.

It is found in 50% to 80% of patients with a temporal bone fracture, and is also seen after nose blowing against obstruction, diving, air travel, ear surgery, nasal packing, anticoagulant use and leukaemia. In children it can follow severe acute otitis media.

Pathophysiology.

Bleeding from damaged mucosa, a fracture line or a skull base lesion fills the middle ear. Obstruction of the Eustachian tube prevents drainage, and blood clots may organise over weeks.

Hearing loss, fullness, blue or black discoloured tympanic membrane, and bleeding from the ear after trauma. Associated features of head injury include cerebrospinal fluid otorrhoea, facial weakness, vertigo and sensorineural loss.

Red flags.

• Head injury with fracture signs (Battle sign, clear otorrhoea).
• Facial palsy.
• Vertigo or sensorineural loss.
• Bleeding disorder or anticoagulation.

Otoscopy shows a blue or dark drum behind an intact drum. Audiometry shows conductive loss (sensorineural loss indicates labyrinthine injury). High resolution CT of the temporal bone defines fractures, ossicular injury and facial canal damage in trauma. Check clotting, platelets and full blood count where a bleeding disorder is suspected.

Differential diagnosis.

• Glomus tympanicum tumour or vascular anomaly.
• Cholesterol granuloma.
• Aberrant internal carotid artery.
• Dehiscent jugular bulb.
• Cholesteatoma.
• Otitis media with effusion.

Most cases resolve in 4 to 6 weeks without intervention. Treat head injury first. Observe hearing and facial function. A ventilation tube is considered when fluid persists beyond 3 months. Surgical exploration is for facial nerve injury, ossicular dislocation, or persisting conductive loss. Review any anticoagulant and correct a coagulopathy.

• Phytomenadione (warfarin treated patients with an INR over 10 or with bleeding): 1 to 2.5 mg orally once, or 5 mg IV slowly over 20 minutes for bleeding; repeat after 24 hours if INR remains raised; maximum 10 mg in a single dose; monitor INR at 12 to 24 hours; use the lower dose in older adults.

No drops are placed in the ear if there is a cerebrospinal fluid leak or a perforation with a fracture.

Monitoring. Audiometry at 6 weeks and 3 months, and earlier with new symptoms.

Referral and escalation. Neurosurgery and ENT for skull base fracture, cerebrospinal fluid leak or facial palsy.

Special groups. Children with unexplained haemotympanum need assessment for bleeding disorders and non-accidental injury.