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MYRINGITIS BULLOSA (Bullous Myringitis)

A Comprehensive Review for 50 Marks

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1. DEFINITION

Scott-Brown's Otorhinolaryngology (8th ed.): Defined as an acute, painful condition with blood-filled vesicles limited to the tympanic membrane and the innermost part of the EAC, most often viral in aetiology.

Dhingra's Diseases of ENT (7th ed.): A form of acute otitis externa confined to the drum with blister formation, associated with severe otalgia disproportionate to clinical findings.

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2. HISTORICAL BACKGROUND

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3. INCIDENCE AND EPIDEMIOLOGY

• Occurs at any age; most common in children and young adults
• Peaks during autumn and winter (viral epidemic seasons)
• Often associated with upper respiratory tract infections (URTI)
• Can occur in outbreaks (epidemic form) or sporadically
• No significant sex predilection
• Bilateral involvement in ~10–15% of cases

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4. AETIOLOGY

A. Viral (PRIMARY — most common)

B. Bacterial (SECONDARY / disputed primary role)

• Mycoplasma pneumoniae — historically considered the most important bacterial cause, but Harrison's (21st ed., p. 5433) now states: "Little evidence supports the commonly held belief that this organism is an important cause of otitis media, with or without bullous myringitis." This represents a significant paradigm shift.
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus

C. Idiopathic

• Significant proportion (~20–30%) have no identifiable cause

D. Predisposing Factors

• Recent URTI
• Immunosuppression
• Trauma to EAC
• Swimming / water sports
• Cold weather exposure

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5. PATHOGENESIS

┌─────────────────────────────────────────────────────────────┐
│                    PATHOGENESIS FLOWCHART                    │
└─────────────────────────────────────────────────────────────┘

         Viral/Bacterial Agent
                 │
                 ▼
    Inhalation → URTI → Spread via
    Eustachian tube OR direct invasion
    of EAC skin
                 │
                 ▼
    Invasion of epithelial lining of TM
    (mucosal + squamous epithelium)
                 │
                 ▼
    Acute inflammatory reaction:
    • Vasodilatation
    • Increased vascular permeability
    • Neutrophil & lymphocyte infiltration
                 │
                 ▼
    Fluid (serous/haemorrhagic) accumulates
    BETWEEN layers of TM epithelium
    (subepithelial cleft)
                 │
                 ▼
    Formation of BULLAE/BLEBS
    on lateral TM surface
    (±adjacent bony meatus)
                 │
         ┌───────┴──────────┐
         ▼                  ▼
   Bleb ruptures        Bleb persists
   → serosanguineous    → resolves
     discharge          spontaneously
         │
         ▼
   Pain relief after rupture
   + risk of secondary infection

• Subepithelial oedema with fibrinous exudate
• Haemorrhagic extravasation into the subepithelial space
• Infiltration by polymorphonuclear leukocytes
• Fibrin deposition within bullae fluid
• No perforation of the TM in uncomplicated cases

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6. ANATOMICAL CONSIDERATIONS

1. Lateral (squamous) epithelium — site of bleb formation
2. Middle fibrous layer — usually spared
3. Medial (mucosal) layer — may show hyperaemia

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7. CLINICAL FEATURES

Symptoms

Signs

Cummings (7th ed., p. 2011): "The hallmark is severe otalgia with blood-filled vesicles on the TM; the pain often remits dramatically when bullae rupture."

Hazarika: Emphasises that the pain is out of proportion to the otoscopic findings and is a key diagnostic clue.

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8. OTOSCOPIC APPEARANCE

Stage 1 (Early):
  • Hyperaemia of TM
  • Mild oedema
  • Small serous vesicles

Stage 2 (Established):
  • Well-formed hemorrhagic bullae
  • Blood-filled blebs on TM & EAC
  • Extreme tenderness on speculum insertion

Stage 3 (Resolution):
  • Spontaneous rupture of blebs
  • Serosanguineous fluid in EAC
  • TM shows resolution of blebs
  • Drum surface may appear granular

Stage 4 (Recovery):
  • TM returns to near-normal
  • Mild residual erythema
  • No perforation

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9. INVESTIGATIONS

A. Routine (Primarily Clinical Diagnosis)

B. Targeted Investigations (when indicated)

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10. FLOWCHART: DIAGNOSTIC ALGORITHM

┌──────────────────────────────────────────────────────────────┐
│              DIAGNOSTIC ALGORITHM FOR MYRINGITIS BULLOSA      │
└──────────────────────────────────────────────────────────────┘

Patient presents with:
SEVERE OTALGIA + URTI history
         │
         ▼
Otoscopy / Otoendoscopy
         │
         ├──────────────────────────────────────────────────────┐
         ▼                                                      │
Bullae / Vesicles on TM?                                       │
    │                                                           │
    ├─── YES ──►  Assess Bleb Character                        │
    │               │                                           │
    │    ┌──────────┴───────────────────────────┐              │
    │    ▼                                       ▼             │
    │ Serous/Serosanguineous              Haemorrhagic         │
    │ blebs on TM only                   blebs on TM + EAC    │
    │    │                                       │             │
    │    ▼                                       ▼             │
    │ Myringitis Bullosa                Myringitis Bullosa     │
    │ (milder form)                     (severe form)          │
    │                                                           │
    └─── NO ──► Consider differentials ────────────────────────┘
                   (see Section 12)

         │
         ▼
Assess Tympanic Membrane Mobility
(Pneumatic otoscopy)
         │
    ┌────┴────────────────────┐
    ▼                         ▼
MOBILE (NORMAL)           NON-MOBILE / BULGING
    │                         │
    ▼                         ▼
MYRINGITIS BULLOSA        Consider AOM with
(confirm)                 effusion/perforation

         │
         ▼
Assess HEARING (Tuning fork / PTA)
         │
    ┌────┴───────────────────┐
    ▼                        ▼
Conductive HL             Sensorineural HL
(mild, <40 dB)            (>40 dB, vertigo)
    │                        │
    ▼                        ▼
Standard management     Urgent Audiology
                         MRI/HRCT; IV steroids
                         consider labyrinthitis

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11. DIFFERENTIAL DIAGNOSIS

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12. COMPLICATIONS

COMPLICATIONS OF MYRINGITIS BULLOSA
             │
    ┌────────┼─────────────────────┐
    ▼        ▼                     ▼
 OTOLOGICAL  AUDIOLOGICAL       SYSTEMIC
    │             │                 │
    ├─ Secondary  ├─ Conductive HL  ├─ Mycoplasma
    │  bacterial  │  (transient)    │  pneumonia
    │  otitis     │                 │
    │  externa    ├─ SNHL           ├─ Viral
    │             │  (rare but      │  dissemination
    ├─ Otitis     │  serious)       │  (immunocomp.)
    │  media with │                 │
    │  effusion   └─ Tinnitus /     └─ Labyrinthitis
    │                Vestibular
    ├─ Perforation    dysfunction
    │  of TM (very
    │  rare, usually
    │  via rupture)
    │
    └─ Persistent
       myringitis
       (granular)

• Incidence ~25–35% (Cummings)
• Mechanism: Viral cochleitis / labyrinthitis; endolymphatic hydrops
• Usually transient, resolves with treatment
• Permanent SNHL rare but documented
• Vertigo may accompany — suggests labyrinthine involvement

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13. MANAGEMENT

FLOWCHART: MANAGEMENT ALGORITHM

┌─────────────────────────────────────────────────────────────────┐
│                  MANAGEMENT FLOWCHART                            │
│                  MYRINGITIS BULLOSA                              │
└─────────────────────────────────────────────────────────────────┘

CONFIRMED DIAGNOSIS: MYRINGITIS BULLOSA
              │
              ▼
    ASSESS SEVERITY
              │
    ┌─────────┴──────────────────────────────┐
    ▼                                         ▼
UNCOMPLICATED                           COMPLICATED
(mild-moderate otalgia,                 (severe SNHL, vertigo,
conductive HL only,                     systemic illness,
immunocompetent)                        immunocompromised)
    │                                         │
    ▼                                         ▼
CONSERVATIVE MANAGEMENT              HOSPITALISATION CONSIDERED
    │                                         │
    ├── Analgesia (first priority)            ├── IV antibiotics
    │   • NSAIDs (Ibuprofen/Diclofenac)       │   (if bacterial)
    │   • Paracetamol                         ├── Oral/IV steroids
    │   • Topical phenol/lignocaine EAC       │   (for SNHL)
    │                                         ├── Audiovestibular
    ├── Topical Antibiotics                   │   workup
    │   (OPTIONAL — debated)                  └── ENT / Audio
    │   • Ciprofloxacin ear drops                 follow-up
    │   • Neomycin-polymyxin drops
    │
    ├── Systemic Antibiotics
    │   (DEBATED — give if:)
    │   • Suspected bacterial superinfection
    │   • Suspected Mycoplasma (macrolide)
    │   • High fever, toxic patient
    │   • Amoxicillin-clavulanate 1st line
    │   • Azithromycin / Clarithromycin
    │     (for Mycoplasma)
    │
    ├── MYRINGOTOMY / INCISION OF BLEBS
    │   (controversial but practiced)
    │   • Immediate pain relief
    │   • Dhingra: "Incision of blebs gives
    │     dramatic pain relief"
    │   • Scott-Brown: Reserved for severe
    │     unresponsive pain
    │   • Risk: Secondary infection, perforation
    │
    ├── Avoid EAR DROPS with alcohol
    │   (causes severe pain on raw epithelium)
    │
    └── FOLLOW-UP at 2–4 weeks
        • Audiometry
        • Otoscopy
        • Resolution confirmation

A. Analgesia

• First priority in management (Dhingra, Hazarika, Zakir Hussain)
• Oral NSAIDs: Ibuprofen 400–600 mg TDS or Diclofenac 50 mg TDS
• Topical EAC analgesia: Phenol/glycerin drops or 2% Lignocaine — applied carefully avoiding bleb disruption
• Opioids: Reserved for severe intractable pain

B. Antimicrobials

• Ciprofloxacin 0.3% ear drops: reduces risk of secondary bacterial infection
• Framycetin/neomycin: alternative
• Caution: avoid ototoxic drops (aminoglycosides in suspected TM perforation)

Note: Routine antibiotic use in uncomplicated viral myringitis bullosa is NOT recommended per current evidence (Harrison's 21st ed.; Scott-Brown 8th ed.)

C. Myringotomy / Bleb Incision

• Dhingra (7th ed.): Deliberately incising blebs provides immediate, dramatic pain relief
• Technique: Under otomicroscopy, a fine myringotomy knife or needle used to open the bleb
• Sterile technique essential; bleb fluid sent for culture if recurrent
• Stell & Maran's and Cummings: Reserve for severe refractory cases

D. Corticosteroids

• Indicated when SNHL is documented
• Prednisolone 1 mg/kg/day × 7–10 days, tapering
• Evidence: Limited but extrapolated from viral labyrinthitis literature
• Intratympanic steroids considered for severe/refractory SNHL (recent practice)

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14. PROGNOSIS

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15. COMPARISON WITH RELATED CONDITIONS

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16. RECENT ADVANCES (2015–2024)

A. Paradigm Shift in Mycoplasma Role

• Harrison's 21st ed. (2022): Evidence against Mycoplasma as primary cause of bullous myringitis has led to reduced routine use of macrolides
• Systematic reviews (2017–2021) found limited evidence linking M. pneumoniae to acute bullous myringitis

B. Narrow-Band Imaging (NBI) Endoscopy

• Emerging technology (as demonstrated in the image above from PMC clinical data)
• NBI enhances vascular patterns, allowing differentiation of myringitis bullosa (deep purple hemorrhagic enhancement) from AOM, granular myringitis, and otomycosis
• Reduces unnecessary antibiotic prescription by improving diagnostic specificity
• Published: Otolaryngology Head Neck Surgery, 2020–2023

C. Intratympanic Steroids for SNHL

• Salvage therapy for steroid-refractory SNHL complicating myringitis bullosa
• Dexamethasone 4 mg/mL intratympanic injection
• Evidence from cochlear hydrops and sudden SNHL literature extrapolated

D. Viral Genomics and Metagenomics

• Next-generation sequencing (NGS) of bleb fluid in recent studies
• Identified novel viral strains (novel rhinovirus subtypes, bocavirus) as causative agents
• Changes understanding of "idiopathic" cases

E. Topical Antiviral Ear Drops (Investigational)

• Acyclovir topical formulations under investigation for HSV/VZV-related bullous myringitis
• No current standard of care; early-phase research

F. COVID-19 Association

• Case reports (2021–2022) of SARS-CoV-2 causing myringitis bullosa
• Mechanism: direct viral invasion via Eustachian tube or haematogenous spread
• Emphasises continued viral aetiological relevance

G. Telemedicine and Otoscope AI

• AI-assisted otoscopy (smartphone adapters) improving diagnosis in primary care
• Reduces over-prescription of antibiotics by accurately identifying bullous vs non-bullous TM changes

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17. SUMMARY TABLE: KEY POINTS FOR EXAMINATION

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REFERENCES

1. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery (8th ed.) — Chapter: Inflammatory Conditions of the External Ear
2. Cummings Otolaryngology — Head and Neck Surgery (7th ed., 2021) — p. 2011; Chapter: Diseases of the External Ear
3. Stell and Maran's Otorhinolaryngology and Head & Neck Surgery (5th ed.) — Chapter: Otitis Externa and Myringitis
4. Dhingra's Diseases of Ear, Nose and Throat (7th ed., 2018) — Chapter 8: Diseases of the Tympanic Membrane
5. Hazarika P. — Textbook of Ear, Nose and Throat Diseases (12th ed.) — Myringitis section
6. Zakir Hussain — Clinical Otorhinolaryngology — Tympanic membrane disorders
7. Harrison's Principles of Internal Medicine (21st ed., 2022) — p. 5433: Mycoplasma pneumoniae (reassessment of bullous myringitis association)
8. Kotikoski MJ et al. — "Viral etiology of bullous myringitis" — Pediatr Infect Dis J, 2004
9. Roberts DB — "The etiology of bullous myringitis and the role of Mycoplasma" — Pediatrics, 1980
10. Bhutta MF — "Acute otitis media and bullous myringitis" — Otolaryngology Head Neck Surg, 2020
11. Patel VA et al. — "NBI endoscopy for middle ear pathology" — JAMA Otolaryngol, 2021
12. Marchisio P et al. — "Diagnosis and management of acute bullous myringitis" — Ann Otol Rhinol Laryngol, 2019

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Exam Tip: In a 50-mark question, examiners look for: (1) clear definition, (2) detailed aetiology with the Mycoplasma controversy, (3) pathogenesis mechanism with layers of TM involved, (4) clinical features emphasising disproportionate pain, (5) otoscopic staging, (6) differential diagnosis table, (7) management flowchart with the myringotomy debate, (8) complications especially SNHL, and (9) at least 3–4 recent advances. The preservation of TM mobility (unlike AOM) and the hemorrhagic nature of blebs are the two most exam-tested distinguishing features.