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Summary Table

Category	Details
Risk Factors	Children (peak age 2-8 years), young adults; recent upper respiratory tract infection (URI); winter season; daycare attendance; same risk factors as acute otitis media (AOM)
Etiology	Same pathogens as AOM: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Group A Streptococcus, Staphylococcus aureus; viral co-infections (RSV, influenza); historically attributed to Mycoplasma pneumoniae but modern evidence shows this link is weak
Patient Presentation	Sudden onset of severe otalgia (often described as waking the patient from sleep), preceded by URI symptoms (congestion, cough); scant serosanguineous otorrhea if bullae rupture; hearing loss; fever more common than in uncomplicated AOM
Classic Physical Exam	Hemorrhagic or serosanguineous bullae/vesicles on an erythematous tympanic membrane (TM); bullae confined to the TM surface (inner or outer); decreased or absent light reflex; decreased TM mobility on pneumatic otoscopy; TM thickening and erythema
Key Diagnostic Results	Clinical diagnosis via otoscopy; no labs or imaging required; tympanocentesis reserved for refractory cases or aspiration for pain relief; audiometry may reveal conductive, sensorineural, or mixed hearing loss
Management	High-dose amoxicillin (80-90 mg/kg/day) as first-line, same as AOM; aggressive analgesia (acetaminophen, ibuprofen, topical benzocaine); bulla aspiration for severe pain; macrolides for penicillin allergy; watchful waiting is generally NOT appropriate
Keywords	"Hemorrhagic bulla on the tympanic membrane," "severe otalgia with URI prodrome," "serosanguineous ear drainage," "bloody blister on the eardrum," "woke from sleep with ear pain"

1. Pathophysiology

Bullous myringitis is considered a severe form of acute otitis media (AOM), where the TM demonstrates bulging andblistering, as opposed to standard AOM which only shows bulging without blistering. The fundamental understanding here is that this is not a separate disease entity. It represents AOM with an additional feature: hemorrhagic bullae formation between the layers of the tympanic membrane.

The pathophysiological sequence begins with an upper respiratory tract infection that causes eustachian tube dysfunction. Mucosal edema and congestion impair normal drainage of the middle ear, creating a favorable environment for bacterial proliferation. The infecting organisms, which are the same pathogens found in standard AOM, trigger an inflammatory response in the TM. The acute inflammation produces subepithelial fluid collections between the outer epithelial layer and the middle fibrous layer of the tympanic membrane, forming vesicles or bullae. These bullae fill with serosanguineous or hemorrhagic fluid due to the rich vascular supply of the TM.

The reason patients experience pain that is notably more severe than typical AOM relates to the distension of the TM layers by expanding bullae. The TM has sensory innervation from the auriculotemporal branch of CN V3 and Arnold's nerve (auricular branch of CN X), making it exquisitely sensitive to this type of stretching injury. When the bulla ruptures, patients often experience sudden pain relief accompanied by bloody or serosanguineous drainage from the ear canal.

Over half of patients with bullous myringitis demonstrate some degree of sensorineural hearing change. The mechanism is not fully understood, but proposed explanations include toxic labyrinthitis via the semipermeable round window membrane, cochlear transudation with increased intralabyrinthine pressure, and virus-induced neural degeneration. Stapedial reflex testing in affected patients shows recruitment, suggesting the site of injury is at the cochlea rather than retrocochlear. This hearing loss is usually temporary and recovers in the majority of cases, but it is more common than traditionally believed and warrants audiometric follow-up.

A historically tested association is with Mycoplasma pneumoniae. Early volunteer inoculation studies in the 1960s found that subjects infected with Mycoplasma frequently developed bullae on the TM, cementing this association in traditional teaching. However, critical review of the literature has shown that the isolated pathogens in bullous myringitis are Streptococcus pneumoniae, Haemophilus influenzae, and beta-hemolytic Streptococcus in the same proportions as standard AOM, and evidence for Mycoplasma as a common causative agent is weak.

2. Classification and Clinical Manifestation

Type	Onset	Pain	Otorrhea	TM Findings	Associated Pathology
Bullous Myringitis (Acute)	Acute, preceded by URI	Severe otalgia	Serosanguineous (if bullae rupture)	Hemorrhagic bullae/vesicles on erythematous TM; decreased mobility	Middle ear inflammation (AOM spectrum)
Granular Myringitis (Chronic)	Chronic (>1 month)	Painless or mild	Persistent painless otorrhea	De-epithelialization with granulation tissue on TM surface	External ear pathology extending to TM; requires exclusion of middle ear disease
Eczematoid Myringitis (Chronic)	Chronic	Variable	Scaly, dry drainage	Eczematous changes on TM	Associated with dermatitis of external canal
Fungal Myringitis	Subacute to chronic	Pruritus more than pain	Debris, fungal elements	Fungal hyphae or spores on TM surface	Otomycosis extending to TM

Bullous Myringitis vs AOM

Feature	Bullous Myringitis	Uncomplicated AOM
Pain severity	Severe (often wakes patient from sleep)	Moderate
Fever	More common	Less common
Otoscopy	Bullae + bulging + erythema of TM	Bulging + erythema, no bullae
Hearing loss	Conductive, sensorineural, or mixed	Predominantly conductive
Watchful waiting appropriate?	Generally NO	Yes, in select patients
Bacterial culture positivity	High (majority have positive middle ear cultures)	Variable

3. Diagnostic Workup

Test	Role	Findings
Otoscopic examination	Best initial test AND confirmatory test	Hemorrhagic or serosanguineous bullae on the TM; erythema; decreased light reflex
Pneumatic otoscopy	Adjunct to assess TM mobility	Decreased or absent mobility of the TM
Tympanocentesis	Reserved for refractory cases or pain relief	Culture of middle ear aspirate; also therapeutic (bulla aspiration relieves pain)
Pure-tone audiometry	Assess hearing loss; recommended for all patients	May show conductive, sensorineural, or mixed hearing loss
Tympanometry	Rarely indicated in isolated cases	Type B (flat) tympanogram if effusion present
Laboratory tests	Not routinely indicated	Exception: neonates (<28 days) with fever require full sepsis workup

The diagnosis of bullous myringitis is clinical, based on the presence of one or more blisters on the tympanic membrane, regardless of other findings such as concurrent AOM. This is an important exam concept: the best initial test and the confirmatory test are the same thing, which is direct otoscopic visualization. There is no lab value or imaging study that you need to order to confirm this diagnosis.

In true bullous myringitis, the bullae are confined to the tympanic membrane. If bullae or vesicles are seen in the ear canal or external ear, other diagnoses must be considered, such as Ramsay Hunt syndrome or bullous dermatoses. This is a high-yield distinction. The test-writer will describe vesicle location to steer you toward or away from this diagnosis.

Tympanocentesis can be used in selected cases to confirm middle ear effusion and to culture the offending pathogen, as well as to provide pain relief through bulla aspiration. This is primarily therapeutic rather than diagnostic in routine cases.

Audiometric evaluation is recommended early because the incidence of sensorineural hearing loss is higher than previously thought in bullous myringitis, and it is temporary in many cases. On the exam, if the vignette describes persistent hearing difficulty after resolution of the acute episode, the next step is audiometry.

The only scenario warranting full laboratory evaluation is infants less than 28 days of age with fever and acute bullous myringitis, which requires a complete sepsis workup per AAP guidelines.

4. Management and Treatment

Step	Intervention	Details
First-line antibiotic	High-dose amoxicillin	80-90 mg/kg/day divided BID for 7-10 days (children); 500 mg TID or 875 mg BID for adults
If amoxicillin used within 30 days	Amoxicillin-clavulanate	90 mg/6.4 mg per kg/day (amoxicillin component) divided BID for 7-10 days
Penicillin allergy (non-Type I)	Cefdinir, cefpodoxime, or cefuroxime	Oral cephalosporins; safe if no anaphylaxis history
Penicillin allergy (Type I / IgE-mediated)	Azithromycin or clarithromycin	Azithromycin: 10 mg/kg day 1, then 5 mg/kg/day for 4 days (children); note 20-25% bacterial failure rate
Cannot tolerate PO	Ceftriaxone IM	50 mg/kg/day IM for 3 days
Analgesia	Acetaminophen + ibuprofen	Acetaminophen 500-1000 mg q6h, ibuprofen 400-600 mg q6-8h (adults); topical benzocaine drops if TM is intact
Severe pain refractory to analgesics	Bulla aspiration/myringotomy	Needle aspiration or incision of the bulla provides immediate relief
Follow-up	Reassess at 48-72 hours	If no improvement, broaden antibiotic coverage

The treatment of bullous myringitis is similar to AOM without bullae, with the exception that pain management may require more aggressive treatment. The "watch and wait" approach commonly used in uncomplicated AOM may not be appropriate in bullous myringitis because of the higher recurrence rate and the fact that the majority of patients have a positive bacterial culture of their middle ear effusion. This is one of the most testable points: unlike uncomplicated AOM where observation for 48-72 hours may be appropriate in low-risk patients, bullous myringitis warrants upfront systemic antibiotics.

High-dose amoxicillin is recommended because it achieves high concentrations in the middle ear. The dose is 80-90 mg/kg/day, not the standard 40-45 mg/kg/day. If the patient has received amoxicillin within the previous 30 days, switch to amoxicillin-clavulanate to cover beta-lactamase producing organisms.

For patients with a history of IgE-mediated reaction to amoxicillin (urticaria, anaphylaxis), azithromycin for 5 days is the appropriate alternative. Topical fluoroquinolone drops (ofloxacin) are not indicated unless tympanostomy tubes are in place. This is a common distractor on the exam.

For pain control, the approach is layered: start with systemic analgesics (acetaminophen and/or ibuprofen), add topical anesthetic drops (benzocaine) if the TM is intact and not perforated, and escalate to bulla aspiration if pain remains refractory. Aspiration provides immediate relief by decompressing the distended TM.

Systemic steroids have been proposed to reduce the prevalence of hearing loss, but they are not currently indicated in the routine management of bullous myringitis. If a question offers steroids as a treatment option, this is likely a distractor unless the clinical scenario involves a separate indication.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Acute Otitis Media (uncomplicated)	Both present with otalgia, fever, erythematous TM, and URI prodrome	No bullae on the TM in uncomplicated AOM; bullous myringitis shows hemorrhagic vesicles on the membrane surface; pain in BM is typically more severe
Herpes Zoster Oticus (Ramsay Hunt Syndrome)	Both can show vesicles near the ear and cause hearing loss	In Ramsay Hunt, vesicles appear on the pinna, external auditory canal, and sometimes the palate (not confined to the TM); associated with ipsilateral facial nerve paralysis (CN VII); clear fluid-filled vesicles rather than hemorrhagic bullae
Otitis Externa	Both cause ear pain and drainage	Pain worsens with tragal pressure or pinna traction in otitis externa; the TM is usually normal or only mildly erythematous; canal is edematous and inflamed, not the TM itself
Cholesteatoma	Both can appear as a mass-like lesion on or near the TM	Cholesteatoma appears as a white, pearly mass in the posterosuperior quadrant or pars flaccida; chronic presentation with painless foul-smelling otorrhea; no hemorrhagic bullae
TM Perforation (traumatic)	Both can present with sudden ear pain and bloody drainage	History of trauma (slap, cotton swab, barotrauma); otoscopy shows a visible perforation rather than bullae; no URI prodrome
Myringitis (Granular / Chronic)	Both involve the TM directly	Granular myringitis is chronic (>1 month), presents as painless otorrhea with granulation tissue on the TM; no bullae, no acute onset

The critical discriminator between bullous myringitis and herpes zoster oticus is that facial nerve paralysis associated with clear, fluid-filled TM vesicles is characteristic of herpes zoster oticus. If the vignette describes a patient with ear pain, vesicles, and ipsilateral facial droop or inability to close the eye, you are being tested on Ramsay Hunt syndrome, not bullous myringitis. Conversely, if vesicles are hemorrhagic and confined to the TM with no facial nerve involvement, the answer is bullous myringitis.

6. Traps and High-Yield Pearls

The single most common way students get this topic wrong is by selecting Mycoplasma pneumoniae as the most likely causative organism. Traditional teaching linked bullous myringitis tightly to Mycoplasma, and many older references reinforce this. Modern evidence, however, demonstrates that the bacterial pathogens are the same as standard AOM (S. pneumoniae, H. influenzae, M. catarrhalis). The exam may test whether you know this updated understanding, or it may still present Mycoplasma as a classic association in the context of a community-acquired pneumonia patient who also develops TM bullae. Read the vignette carefully: if the patient has an atypical pneumonia and then develops bullae, Mycoplasma is the intended connection. If the patient is a child with a simple URI who develops hemorrhagic bullae on the TM, the answer is the standard AOM pathogens.

The second trap involves management approach. Students who reflexively apply "watchful waiting" from their AOM algorithm will get this wrong. Bullous myringitis warrants direct antibiotic therapy because of the higher bacterial culture positivity rate and more severe clinical course. The "next best step" when the vignette presents a child with hemorrhagic bullae on the TM, severe pain, and fever is high-dose amoxicillin, not observation.

The third pearl concerns the location of the vesicles. Bullae confined to the TM point to bullous myringitis. Vesicles extending to the ear canal, pinna, or beyond the TM should redirect your thinking toward Ramsay Hunt syndrome. If the vignette adds facial nerve paralysis, that seals it. This is a classic "one detail changes the entire diagnosis" question.

Finally, remember the hearing loss component. Sensorineural hearing loss in bullous myringitis is more common than traditionally taught and is generally temporary, with the cochlea as the likely site of injury. If a question asks about the next step after a patient with resolved bullous myringitis still reports hearing difficulty, the answer is audiometry, not repeat antibiotics or imaging.

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