Patients suffering from IM usually seek medical attention after the subacute onset of the following symptoms:

• Ear congestion and mild hearing loss
• Sensation of fullness or increased pressure in the ear
• Otalgia
• Otorrhea
• Pruritus

Of note, infants may not be able to describe these symptoms and merely manifest their discomfort in form of sleep disturbances, feeding difficulties and constant crying.

The nature and severity of clinical symptoms may hint at a particular causative agent [3]. In this context, Streptococcus pneumoniae has been shown to cause more severe disease than other pathogens commonly associated with IM and AOM. Moraxella catarrhalis is of rather low virulence and rarely results in complications. Infections with haemophilus influenzae frequently comprise both ears and eyes, and these patients may be diagnosed with conjunctivitis-otitis syndrome [6] [7].

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• Otalgia

  Patients suffering from IM usually seek medical attention after the subacute onset of the following symptoms: Ear congestion and mild hearing loss Sensation of fullness or increased pressure in the ear Otalgia Otorrhea Pruritus Of note, infants may not [symptoma.com]

  Bullous Myringitis This is a painful infection characterized by bullae on the tympanic membrane (TM), which has a richly innervated outer epithelium (hence the severe otalgia). [foamcast.org]

  The tympanic membrane becomes very thickened and bulging, resulting in a conductive hearing loss, pain, and otalgia. A fever occurs. Landmarks are difficult to view. In children, the mastoid area may be tender and swollen. [app1.unmc.edu]

  Other complaints include otalgia, itching, aural fullness, hearing loss, and tinnitus. 1, 2, 3, 4, 7, 8 Some authors define myringitis as having an intact tympanic membrane with no hearing deficit 1, 9 whereas others say that perforations are part of [entokey.com]

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Myringitis is diagnosed clinically and in order to do so, the eardrum should be carefully inspected using an otoscope. It is often necessary to clear the external auditory canal from inflammatory secretions and debris to visualize the eardrum. In general, an inflamed tympanic membrane is less translucent than a healthy eardrum. Common signs of inflammation may be observed, with erythema being most characteristic but not pathognomonic of IM. In severe cases, a perforation of the eardrum may be noted.

The aspect of the tympanic membrane may allow for more descriptive diagnoses like bullous myringitis (fluid-filled blisters surrounded by erythematous, opaque tissue), hemorrhagic myringitis (intense redness and possibly blood clots), granular myringitis (presence of granulation tissue) [8], or combinations thereof [9]. However, neither of those diagnoses provides an explanation as to the pathogenesis of the disease. The association of a determined infectious agent with an inflammation of the tympanic membrane requires its isolation or detection by means of other methods, e.g., culture, molecular biological assays. In practice, this is rarely done. Patients are generally treated with analgesics and antibiotics, and further diagnostic measures are reserved for non-responders and those presenting with complicated disease.

Because IM is commonly associated with AOM, pneumatic otoscopy, tympanometry, and acoustic reflectometry may be indicated [10]. In this context, bulging of the tympanic membrane is a strong indicator of middle ear effusion due to AOM.

The following bacteria are most commonly isolated from patients suffering from IM and other forms of AOM [2] [3]:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

As has been implied above, pathogens accounting for upper respiratory infection may spread to the ears and compromise the tympanic membranes. While some of the aforementioned bacteria may fall into this category, viruses are better known to cause such complications, particularly [4]:

• Respiratory syncytial virus
• Influenza A and B viruses
• Adenoviruses

Of note, fungi may cause IM, but this condition is rare. It mostly affects immunocompromised patients [5].

Infectious myringitis (IM) is an inflammation of the tympanic membrane due to an infection with distinct types of pathogens. IM is often considered a form of acute otitis media (AOM) and accordingly, the broad spectrum of agents that may cause AOM may also be involved in eardrum infections. However, IM may not only be associated with a more extensive inflammation of auricular tissues but commonly occurs in the temporal context of upper respiratory infection. Most IM patients are children [1].

1. Bhutta MF. Epidemiology and pathogenesis of otitis media: construction of a phenotype landscape. Audiol Neurootol. 2014; 19(3):210-223.
2. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatr Infect Dis J. 1997; 16(4):449-456.
3. Palmu AA, Herva E, Savolainen H, Karma P, Makela PH, Kilpi TM. Association of clinical signs and symptoms with bacterial findings in acute otitis media. Clin Infect Dis. 2004; 38(2):234-242.
4. Heikkinen T. Role of viruses in the pathogenesis of acute otitis media. Pediatr Infect Dis J. 2000; 19(5 Suppl):S17-22; discussion S22-13.
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9. Elzir L, Saliba I. Bullous hemorrhagic myringitis. Otolaryngol Head Neck Surg. 2013; 148(2):347-348.
10. Shand KD, Campe K. Innovative technologies in diagnosing acute otitis media. Jaapa. 2016; 29(1):37-41.