Symptom onset is mostly acute and only one ear is affected [9]. While older children, adolescents and adults usually present with throbbing otalgia, a feeling of increased pressure, fullness or ear congestion and muffled hearing, young pediatric patients express their discomfort by feeding and sleeping difficulties and constant crying. Otorrhea and pruritus may be present but are not exclusion criteria. Some patients claim dizziness and vertigo which may result from involvement of the organ of equilibrium.

Anamnesis often reveals recent upper respiratory tract infections. Also, many BM patients use to regularly clear their external auditory channels or report other traumas.

Otoscopic examination reveals fluid-filled blisters between the outer epithelial and middle fibrous layer of the tympanic membrane. In a minority of BM patients, such bullae are also present in the external auditory meatus. Number and size of blebs may vary; they do not necessarily cover the whole tympanic membrane. A bulging tympanic membrane may indicate otitis media and middle ear effusion.

• Fever

  Earache and fever were more common in bullous myringitis than in AOM. However, the condition resolved rapidly and the short-term outcome was good. [ncbi.nlm.nih.gov]

  Related Cases Disease: Bullous Myringitis | Ear Disorders | Ear Infections Symptom/Presentation: Ear Pain | Fever and Fever of Unknown Origin | Rhinitis Specialty: General Pediatrics | Infectious Diseases | Otolaryngology Age: Toddler To Learn More To [pediatriceducation.org]

  It usually begins with a head cold causing severe pain in the ear, hearing loss and fever. Examination of the ear may reveal the drum to have a clear or reddish blister on it. This condition can be very painful. [med.uth.edu]

  Synonym: bullous fever. (05 Mar 2000) bullous impetigo of newborn Usually, widely disseminated bullous lesions appearing soon after birth, caused by infection with Staphylococcus aureus. [m.kmle.co.kr]

  Babies who develop fevers should receive medical care if they are less than two months old. [memd.me]

• Severe Pain

  It usually begins with a head cold causing severe pain in the ear, hearing loss and fever. Examination of the ear may reveal the drum to have a clear or reddish blister on it. This condition can be very painful. [med.uth.edu]

  Small fluid-filled blisters form on the eardrum and cause severe pain. More to Know More children get bullous myringitis than adults. [kidshealth.org]

  […] of severe pain in the ear. [medical-dictionary.thefreedictionary.com]

• Sepsis

  Neoplasm nerve newborn nondisplaced nontraumatic obstetrical trauma obstruction organ Osteochondrosis pelvic percent third degree posterior postprocedural prosthesis psychogenic F45.8 pulmonary Puncture region renal respiratory second degree secondary sepsis [books.google.com]

  Labyrinthitis, meningitis, intracranial sepsis or facial nerve palsy are very rare and occur in less than 1 in 1,000. [patient.info]

  Sepsis G. Leukemia 127. A 72-year-old African American female (AAF) was admitted from a nursing home with complaints of abdominal pain, nausea and vomiting, dizziness, confusion and double vision for 5 days. [proprofs.com]

• Pallor

  There is no jaundice or pallor. BP132/83 mmHg. She has scratch marks all over her arms, abdomen, shoulders and thighs. She denies changing her body cream, and toilet soap. Her diet has not changed and is homemade most of the time. [proprofs.com]

• Rhinitis

  We studied 74 patients with BM aged 0 to 83 years (average age: 8.53), of which 65 patients had allergic rhinitis and others nasal disorders. Most patients had a sudden onset of very severe otalgia, but rarely had a high temperature. [jstage.jst.go.jp]

  The symptoms of upper respiratory tract infection (rhinitis in 93% and cough in 73% of events) were present in a majority of cases. [ncbi.nlm.nih.gov]

  PNEUMATOCELE--seen in fracture of frontal sinus,---- PROCESSUS COCHLEARIFORMIS--attaches to handle of mallues, " RESP.ALLERGY--house dust,"--- " RANADIER'S OPERATION---done in Petrositis," CHRONIC RETROPHARYNGEAL ABSCESS--due to caries spine,- "SICCA RHINITIS [mypgnotes.com]

  MTC and the Management of the Thyroid in MEN2 283 Nasal Foreign Bodies Epistaxis and Nasal Trauma 285 Signs and Symptoms 286 Aetiology 287 Nasal Trauma 288 Management of Choanal Atresia 291 Clinical Presentation 292 Transpalatine Approach 293 Allergic Rhinitis [books.google.com]

• Pharyngitis

  The physiology of swallowing, esophageal motility, and oral and pharyngeal dysphagia are described in Chap. 53. Esophageal diseases can be manifested by impaired function or pain. [accessmedicine.mhmedical.com]

  In some patients with pharyngitis, ear pain can be the primary complaint even when the ear is normal. [aafp.org]

  Part of middle1/3 of sternomastoid & tonsil is pused medially " PAROSMIA---PERVERSION OF SMELL," "PHARYNGITIS- MEMBRANOUS---causes--streptococcal, ludwig's angina, diptheria, "- PHARYNGOMAXILLARY ABSCESS---medial bulge of pharynx, " PLEOMORPHIC ADENOMA [mypgnotes.com]

  Pharyngitis G. Foreign body inhalation H. Gastric ulcer I. GERD 97. A 75 year old woman presents with fever and worsening pain in the left lower quadrant of the abdomen for three days. [proprofs.com]

• Sore Throat

  I was also diagnosed with strep throat. The initial illness came on quickly with sore throat, body aches and fever, and 24 hours later I had a feeling like there was fluid in my left ear and severe ear pain. The pain was like a tooth abscess. [wisegeek.org]

  Evaluation of the patient with sore throat, earache, and sinusitis: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):153–187, ix. Copyright © 2008 by the American Academy of Family Physicians. This content is owned by the AAFP. [aafp.org]

  The practitioner may look in the throat for signs of tonsillitis or sore throat, check the lungs for indications of pneumonia and feel the neck to assess stiffness and check for swollen lymph nodes. [memd.me]

  Symptoms : There are four pairs of sinuses and the symptoms differ with respect to location and extent of infection.Ethmoid sinusitis is located behind the eyes and any infection in ethmoid may cause nasal congestion, postnasal drip, sore throat, pain [symptoms-causes-treatment.blogspot.com]

  A 44-yr-old male presents with cough and sore throat. He has on and off epigastric abdominal pains, change of voice and painful swallowing .He also complained that his wife found him irritating because he has to clear his throat repeatedly. [proprofs.com]

• Common Cold

  Cold 152 Rhinosinusitis in Recurrent Acute Otitis Media 158 Immune WorkupManagement for Recurrent Otitis Media 164 Immunoglobulins for Recurrent Acute Otitis Media 169 Otitis Media with Effusion 171 Antibiotics for Otitis Media with Effusion 175 Steroids [books.google.com]

  The most common of these is mycoplasma. It is often found along with the common cold or other similar infections. The condition is most often seen in children, but it may also occur in adults. The main symptom is pain that lasts for 24 to 48 hours. [medlineplus.gov]

  In addition there may be common cold, fever, headache and partial hearing loss for 2-3 days until the blisters heal completely. There would be radiating pain for few days, even after the infection is treated. [diseasespictures.com]

  Cold, Common Symptoms, Community-Acquired Pneumonia, Computed Tomographic Imaging, Congestive Heart Failure, Conjunctivitis, Constipation, Contraception, COPD, Corneal Abrasions, Corticosteroids, Cultural Competence, Dancers, Daycare Exclusions, Decision [hippoed.com]

  Common cold is characterized by runny nose and sneezing and intense form would have throat infection. But sinus pain will have all the above symptoms accompanied with tenderness in your face. [symptoms-causes-treatment.blogspot.com]

• Yawning

  By Richard Klasco, M.D Photo Credit Ask Well Photo Credit Why Do We Yawn? Reading about yawning makes people yawn. You are probably yawning right now. By Roni Caryn Rabin Latest Search Latest Articles Search Articles 13844 results for sorted by [nytimes.com]

  Pain aggravated by chewing or head movement May have trigger point Can be caused by clenching, bruxism, TMJ syndrome, and dental or oral disorders Eagle's syndrome (elongation of styloid process) 28 Deep, unremitting pain exacerbated by swallowing, yawning [aafp.org]

  ^ a b Rosenfeld RM, Culpepper L, Yawn B, Mahoney MC (June 2004). "Otitis media with effusion clinical practice guideline". Am Fam Physician. 69 (12): 2776, 2778–9. PMID 15222643. ^ "Otitis media with effusion: MedlinePlus Medical Encyclopedia". [en.wikipedia.org]

• Overeating

  Over 30 medical and health specialties covered. Over 39,000 entries, plus enyclopedic entries of significant terms. Over 50 new drug entries. High quality images and tables. [books.google.ro]

  Examination shows a vesicular or bullous eruption over the tympanic membrane and adjacent bony canal wall. In the early stages, the vesicles are erythematous and surrounded by injected epithelium. [doctorsgates.blogspot.com]

  Fifteen patients with 21 ears diagnosed as bullous myringitis were seen over a 24-month period. [ncbi.nlm.nih.gov]

  It usually affects people aged over 70. Improving Diagnostic. Acute myringitis is an inflammation of the tympanic membrane that occurs alone or in ass. The ear examination is usually abnormal. [decisionsexpert.ga]

• Diarrhea

  Infants and Young Children May Have Other Symptoms Diarrhea Vomiting Refusal to eat Poor sleeping Irritability Diagnosis of Acute Ear Infection Healthcare providers use otoscopes to view the eardrum because they cannot see directly into the middle ear [memd.me]

  Dislocation, URI, Abdominal Pain, ACS, Amiodarone Toxicity, Analgesia, Appendicitis, Arterial/Venous Insufficiency, Asthma, Cardiac, Cardiothoraic Surgery, Cellulitis, Child Abuse, Compartment Syndrome, Concussion, Crush Injury, Death, Depression, Diabetes, Diarrhea [hippoed.com]

  Media Include: Irritability, whining, fussing or crying in infants and children Partial or complete loss of hearing Feeling of blocked or plugged ear Buzzing or ringing sound in the ear Fever or pain Discharge that appears when the eardrum ruptures Diarrhea [naturalremedies.org]

  Being the astute clinician you do a complete history and on review of systems you also get a history of arthralgias and occasional bloody diarrhea over the past few years. [proprofs.com]

  For every 14 children treated with antibiotics, one child has an episode of either vomiting, diarrhea or a rash. [11] If pain is present, pain medications may be used. [en.wikipedia.org]

• Blurred Vision

  A 65 year old man presents with blurred vision in his right eye with intermittent loss of vision. He describes it as a “curtain passing vertically” across the visual field. He suffers from uncontrolled diabetes and hypertension. [proprofs.com]

• Hip Pain

  A 78 year old man presents with right hip pains that started over the night. He rates his pain as 8/10. He woke up suddenly to pick up a call, and felt dizzy before passing out. [proprofs.com]

• Otalgia

  Bullous myringitis is manifested by moderately severe otalgia associated with vesicles on the tympanic membrane and medial external auditory canal wall. [ncbi.nlm.nih.gov]

  Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. [aafp.org]

  Myringitis and tissue stretching typically cause severe, throbbing otalgia. As has been indicated above, BM is often associated with otitis media. [symptoma.com]

  Bullous external otitis and bullous myringitis Bullous external otitis presents as sudden, severe otalgia followed by bloody or serosanguinous drainage from the EAC. [otologytextbook.net]

  Most patients had a sudden onset of very severe otalgia, but rarely had a high temperature. [jstage.jst.go.jp]

• Hearing Impairment

  Usually set in during or following an upper respiratory tract infection.A blood staining discharge can be present for a couple of hours.A hearing impairment is common( conductive and /or sensorineural). [vdocuments.site]

  Myringitis, or inflammation of the TM, may be accompanied by hearing impairment and a sensation of congestion and earache. After 3 weeks, acute myringitis becomes subacute and, within 3 months, chronic. [emedicine.medscape.com]

  Fiber-optic bronchoscopy,"- "NORMAL RANGE OF frequency of human haering = 20-20,000 hz," "AUDIBLE SOUND FOR NORMAL HUMANHEARING = 40-45 db," "PROLONGED EXPOSURE TO NOISE LEVELS > 85 db can impair hearing permanently," "RUPTURE OF T.M. [mypgnotes.com]

  Children have impaired hearing following AOM. If aged under 3 with OME, bilateral effusions and mild hearing loss with no speech, language or developmental problems, observe initially. Otherwise, refer for consideration of grommets. [patient.info]

• Hearing Problem

  A 68 year old male patient presents with hearing problems with one of his ears for the past two months. He denies recent history of otitis media, except during childhood. [proprofs.com]

• Facial Pain

  Facial Pain, Falls, Fever, Fibromyalgia, Flashes, Floaters, Fluoroquinolone, fluoroquinolones, Flu Vaccine, Follow up, Foot, Foot Injuries, foreign body removal, Fracture, Fundoscopic Exam, Fundoscopy, Gastroparesis, Genitourinary, Geriatric Medicine [hippoed.com]

  J Orofac Pain. 2004;18(3):226–234. 36. Demez P, Goffart Y, Daele J. Facial pain from visceral origin. Acta Otorhinolaryngol Belg. 2004;58(4):141–142. 37. Nestor JJ, Ngo LK. Incidence of facial pain caused by lung cancer. [aafp.org]

• Irritability

  It helps to relay sound waves to the brain and prevent foreign particles from irritating the middle ear. [wisegeek.org]

  Infants with AOM have vague, nonspecific symptoms (irritability, lethargy, and decreased oral intake). Young children can be irritable, often febrile, and frequently pull at their ears, but they may also be completely asymptomatic. [accessmedicine.mhmedical.com]

  […] the ureter. (05 Mar 2000) bullous oedema vesicae A prominent area of focal oedema involving the bladder mucosa, consisting of elevated masses of edematous tissue or clusters of clear fluid-filled vesicles; often associated with chronic inflammation or irritation [m.kmle.co.kr]

  Itchy Neck Itchy neck is called pruritus in medical terms and this gives you an irritating sensation to scratch the neck very often. There may be reddening of the skin in the neck along with swelling and irritation. [symptoms-causes-treatment.blogspot.com]

  The pain is felt to be due to irritation of the highly innervated outer epithelial layer. The most common pathogens are the same as AOM but Streptococcus pneumoniae is detected more often. [pediatriceducation.org]

• Meningism

  Infection and inflammation may spread to other adjacent tissues and cause mastoiditis or meningitis. BM is primarily caused by infectious agents. [symptoma.com]

  Ferri’s popular "5 books in 1" format provides quick guidance on short QT syndrome, microscopic polyangiitis, fungal meningitis, and much more. This medical reference makes the answers you need even easier to find - anytime, anywhere. [books.google.com]

  Mental status changes can signify a neurologic complication such as brain abscess or meningitis. [clinicaladvisor.com]

  Labyrinthitis, meningitis, intracranial sepsis or facial nerve palsy are very rare and occur in less than 1 in 1,000. [patient.info]

  Meningitis C. Cerebral abscess D. Pseudo tumor cerebri E. Rupture of berry aneurism 47. [proprofs.com]

• Stroke

  PHANTOM-S trial : Use of the STEMO (Stroke Emergency Mobile – an ambulance with neurologist and a CT scanner for suspected strokes) reduced mean alarm-to-treatment time by 25 minutes (95% CI, 20-29; P An article by Gregg et al in the NEJM discussed incredible [foamcast.org]

  It is more prevalent in elderly patients with neurological disease, particularly stroke, dementia and Parkinson disease. [dermnetnz.org]

  Stroke in evolution 124. A 62-year-old breast cancer survivor visits her physician because of weakness, fatigue, fever, and weight gain 5 years following her radiation therapy. [proprofs.com]

BM is diagnosed after otoscopic examination and visual evaluation of the tympanic membrane. These may require cleaning of the external auditory meatus from any discharge and debris. Special care has to be taken if the condition of the tympanic membrane is not easily assessable because it cannot be visualized before the aforementioned procedure took place.

In order to determine the extent of the disease and to identify its cause, additional diagnostic measures may be necessary.

Pneumatic otoscopy and tympanometry allow for assessment of tympanic membrane mobility and are routinely used to diagnose otitis media and associated middle ear effusion. Acoustic otoscopy may also be employed to this end. This method is based on measuring the tympanic membrane's ability to react to sound waves.

Bacterial cultures established from samples obtained from the external auditory channel or the middle ear (possibly requires tympanocentesis) not only allow to determine the causative agent but are also of great help when deciding on a specific therapeutic approach. Protein content, albumin to immunoglobulin ratio and specific gravity of these samples may be measured to distinguish exudate from transudate if there is any doubt.

An audiogram may be recorded to determine the extent of hearing loss and to locate its cause.

Moderate to severe cases may indicate advanced diagnostic imaging. Otomicroscopy and otoendoscopy may provide detailed information regarding the condition of outer and middle ear. If compromise of neighboring tissues, e.g., adjacent bones and intracranial structures such as meninges, is suspected, magnetic resonance imaging and computed tomography scans should be carried out.

• Streptococcus Pneumoniae

  The bacteria were Streptococcus pneumoniae, Haemophilus influenzae, and beta-hemolytic Streptococcus, in the same percentages as found in (nonbullous) otitis media. [ncbi.nlm.nih.gov]

  Bullous myringitis bullous myringitis A form of primary myringitis that causes painful bullae on the surface of the tympanic membrane, which may occur in a background of otitis media caused by bacterial infections, including Streptococcus pneumoniae, [medical-dictionary.thefreedictionary.com]

  There are two main culprits: Streptococcus pneumoniae and Mycoplasma pneumoniae. Streptococcus pneumoniae is one of the major causes of pneumonia. It usually attacks the respiratory system but can take residence up in the ear. [doctorshealthpress.com]

  Streptococcus pneumoniae is the most common, followed by Haemophilus influenzae and Moraxella catarrhalis. Examination shows a vesicular or bullous eruption over the tympanic membrane and adjacent bony canal wall. [doctorsgates.blogspot.com]

Adequate treatment should be provided as soon as possible in order to prevent spread of infection and inflammation to adjacent tissues. Treatment of BM is mainly based on topical and possibly systemic application of antibiotics and non-steroidal anti-inflammatory drugs.

Ideally, antimicrobials are chosen based on an antibiogram, but antibiotics are often prescribed before such an analysis is available. If symptoms subside over the course of few days - which is the case in most BM patients - antibiotic therapy doesn't need to be changed and should be continued as originally planned. However, resistant bacteria have been isolated from otitis media and BM, notably methicillin-resistant Staphylococcus aureus, and may account for lack of response to therapy.

Non-steroidal anti-inflammatory drugs may contribute to reduce inflammation, pain and pruritus and are usually preferred over corticosteroids [10].

Additionally, patients may benefit from ear cleaners and antihistamines.

More severe cases associated with middle ear effusion may require myringotomy. This procedure accelerates pressure reduction and avoids spontaneous bursting of the tympanic membrane. The incision into the tympanic membrane usually heals fast and without complications. While this is certainly a benefit with regards to healing, it may interfere with continuous drainage of the middle ear. In this context, a small tube may be inserted into the tympanic membrane to maintain the possibility for fluid discharge. This tympanostomy may, however, lead to permanent perforation of the tympanic membrane and should thus not be carried out routinely.

Other surgical interventions are rarely needed to treat BM, but may be indicated if the tympanic membrane spontaneously bursts. Here, chronic otitis media and myringitis may be prevented by myringoplasty, i.e., closure of the perforation of the tympanic membrane. Myringoplasty is considered a very successful procedure and up to 90% of patients treated in this manner re-form their tympanic membrane.

Prognosis of BM is usually favorable. Indeed, the condition is often self-limiting, but adequate treatment is indicated to relieve otalgia and to prevent serious complications:

• Sensorineural and conductive hearing loss may be associated with BM [8].
• Perforation of the tympanic membrane may occur.
• Close proximity of the facial nerve may result in nerve damage and facial paralysis.
• Infection and inflammation may spread to other adjacent tissues and cause mastoiditis or meningitis.

BM is primarily caused by infectious agents. And although there is general agreement on this fact, a literature review reveals that opinions regarding its precise causative agents differ widely. Some consider BM to be mainly triggered by viral agents, but more recent research argues for bacteria to account most commonly for this condition. There has been considerable disagreement regarding the role of Mycoplasma pneumoniae in BM and contrary to what has been assumed for a long time, this species is now considered to rarely cause BM [4] [5].

Presumably, BM is triggered by the same bacterial and viral agents that also cause otitis media. This is consistent with BM being either a specific form or partial finding of otitis media and externa. Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are most frequently isolated from otitis media [6]. Furthermore, Staphylococcus aureus, other streptococci and staphylococci as well as Enterobacteriaceae and Pseudomonas aeruginosa have been described in this context. As has been indicated above, Mycoplasma pneumoniae may be found but is not pathognomonic for BM.

Otitis media and BM often occur following upper respiratory tract infections. Here, pathogens such as adenovirus, coronavirus, rhinovirus and parainfluenza virus may ascend towards the middle ear through the Eustachian tube.

Fungal infections have been described to affect the external auditory meatus, but a causal relation to BM has not yet been proven.

A Finnish research group reported an incidence of more than 5 per 100 person-years [7]. Although this study was focused on children aged less than 2 years, it does point out that BM is not a rare disease. Most BM patients are indeed children; adolescents and young adults are frequently affected, too. Thus, the overall incidence comprising all age groups may be somewhat lower than the above given value.

According to the above mentioned study, BM is diagnosed in about 5% of all otitis media cases.

BM more often occurs in cold and damp seasons and anamnesis frequently reveals recent upper respiratory tract infections.

BM is characterized by blisters or bullae that develop between the outer epithelial layer (Stratum corneum) and the middle fibrous layer (Lamina propia). They may be filled with serous, serosanguineous or sanguineous fluid. Myringitis and tissue stretching typically cause severe, throbbing otalgia.

As has been indicated above, BM is often associated with otitis media. The latter, in turn, is commonly related with functional impairment of the Eustachian tube, reduced aeration of the middle ear, and ascend of pathogens through the auditory tube. Excess opening of the tube may facilitate infection of the middle ear. These facts also explain why otitis media and BM often occur after upper respiratory tract infections. With regards to infectious otitis externa, causative agents may enter the external auditory channel and reach the tympanic membrane.

To date, it is not yet clear why some cases of otitis media or otitis externa are associated with tympanic bullae formation and others aren't.

Patients should be advised on how to clean their external auditory channels without inflicting trauma. Usage of ear plugs may prevent water from entering the ear and contributes to prevention of BM. This measure as well as the use of isopropyl alcohol or similarly acting ear drops is particularly recommended to those patients who suffer from recurrent ear infections.

Any measure to improve immunity may help to directly reduce the incidence of ear infections and may also diminish the rate of respiratory tract infections and subsequent BM.

The middle ear comprises tympanic membrane and ossicles, whereby the latter are located in the tympanic cavity and forward auditory input towards the cochlea. The Eustachian tube connects tympanic cavity and nasopharynx and although this organ is not considered part of the middle ear, it fulfills a variety of physiological and pathophysiological functions that significantly affect the condition of the latter. For instance, it allows for pressure compensation and drainage of fluids that would otherwise accumulate in the tympanic cavity.

Inflammation of the middle ear is termed otitis media and is most frequently caused by microorganisms. Otitis media frequently involves the tympanic membrane and causes myringitis. In some cases, lesions of the tympanic membrane present as fluid-filled bullae and the condition is then designated bullous myringitis (BM) [1]. While most commonly, these blisters are filled with serous fluids, hemorrhagic forms of BM have been reported [2]. To date, there is no general consensus whether BM is indeed an own entity or whether it is merely a partial finding in patients suffering from otitis media. In fact, the bullous inflammation may not be restricted to the tympanic membrane but may spread to the external auditory channel and these patients are then diagnosed with otitis media and externa [3].

Similar to otitis media itself, BM is thought to be primarily triggered by infection with bacteria or viruses. A variety of etiologic agents has been described and will be mentioned below. The condition is associated with severe otalgia and fever. Children are affected more frequently than adults, although BM is not a rare finding in any age group. BM is usually self-limiting, but pain, general discomfort and the risk for serious complications nevertheless indicate at least supportive treatment and, if possible, causative therapy.

Bullous myringitis (BM) refers to a certain type of inflammation of the tympanic membrane that is characterized by the appearance of fluid filled blebs ("bullae") between the outer epithelial and middle fibrous layer of this organ.

Causes

BM is often associated with inflammations of the middle or outer ear. All these conditions are primarily triggered by bacteria and viruses that may ascend through the auditory tube that connects nasopharynx and middle ear or that may simply enter via the external auditory channel.

Interestingly, the medical history of BM patients frequently reveals recent infections of the upper respiratory tract. Here, the causative agent of the latter presumably ascended to the middle ear. Thus, one and the same pathogen probably triggered both conditions.

Symptoms

This disease is most frequently detected in young children. They may express their discomfort in form of feeding and sleeping problems and continuous crying. Children are also observed to frequently touch their aching ear. BM is a painful condition often described as a feeling of increased pressure, fullness or ear congestion. The throbbing pain is felt in one ear only and sets in rather suddenly. A slight hearing loss may result from BM and patients often report muffled hearing. Because the organ of equilibrium is also located in the ear, dizziness and vertigo are not uncommon in middle ear inflammation and BM. Discharge from the external auditory channel may be noted.

Diagnosis

The condition is generally diagnosed upon visual inspection of the tympanic membrane by means of an otoscope. Sometimes, fluids and debris accumulated in the external auditory channel do not allow for visualization of the tympanic membrane and have to be removed first.

While fluid-filled blebs are characteristic for BM, the physician may apply additional therapeutic measures to support their diagnosis of otitis media. Here, tympanometry, pneumatic and acoustic otoscopy shall be named as possible forms of examination.

In severe cases, when the physician suspects that adjacent osseous tissues or meninges are compromised by infection and inflammation, magnetic resonance imaging and computed tomography scans may be carried out.

Treatment

Although BM is usually self-limiting, drug therapy is indicated to avoid serious complications such as spread to neighboring tissues and hearing loss. Most frequently, application of antibiotics and non-steroidal anti-inflammatory drugs is sufficient to treat the condition.

Inflammation and effusion of the middle ear may require a small incision into the tympanic membrane in order to allow drainage of accumulated fluids. On the other hand, perforations of the tympanic membrane may be closed during surgical interventions.

1. Marais J, Dale BA. Bullous myringitis: a review. Clin Otolaryngol Allied Sci. 1997; 22(6):497-499.
2. Elzir L, Saliba I. Bullous hemorrhagic myringitis. Otolaryngol Head Neck Surg. 2013; 148(2):347-348.
3. Roland PS, Marple BF. Disorders of the external auditory canal. J Am Acad Audiol. 1997; 8(6):367-378.
4. Cramer L, Emara DM, Gadre AK. Mycoplasma an unlikely cause of bullous myringitis. Ear Nose Throat J. 2012; 91(6):E30-31.
5. Mellick LB, Verma N. The Mycoplasma pneumoniae and bullous myringitis myth. Pediatr Emerg Care. 2010; 26(12):966-968.
6. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatr Infect Dis J. 1997; 16(4):449-456.
7. Kotikoski MJ, Palmu AA, Huhtala H, Savolainen H, Puhakka HJ. The epidemiology of acute bullous myringitis and its relationship to recurrent acute otitis media in children less than 2 years of age. Int J Pediatr Otorhinolaryngol. 2003; 67(11):1207-1212.
8. Drendel M, Yakirevitch A, Kerimis P, Migirov L, Wolf M. Hearing loss in bullous myringitis. Auris Nasus Larynx. 2012; 39(1):28-30.
9. McCormick DP, Saeed KA, Pittman C, et al. Bullous myringitis: a case-control study. Pediatrics. 2003; 112(4):982-986.
10. Ciorba A, Bovo R, Rosignoli M, Martini A. Are systemic oral steroids effective for sensorineural hearing loss in bullous myringitis? Considerations from a preliminary study. B-Ent. 2011; 7(2):111-114.