- Case report
- Open Access
Bilateral hemotympanum as a result of spontaneous epistaxis
© Fidan et al; licensee Springer. 2011
Received: 27 July 2010
Accepted: 27 January 2011
Published: 27 January 2011
Hemotympanum is a rare condition and usually depends on a secondary reason. Therefore, idiopathic hemotympanum is rarely seen in the literature. In this paper, we report a case of this problem.
Hemotympanum is most often associated with basilar skull fractures or nasal packing. Only six cases associated with spontaneous epistaxis have been described in the literature [1, 2]. Because of this rare situation, we present the case of a 51-year-old woman with bilateral hemotympanum secondary to spontaneous epistaxis. Initial evaluation must include an audiogram and radiological imaging (computed tomography, magnetic resonance imaging, etc.). Close follow-up of the patient is necessary for reducing the risk of long-term sequelae such as cholesterol granuloma .
A 51-year-old woman was referred to the emergency department with a complaint of epistaxis associated with exercise. She had been sweeping her house when she noticed the epistaxis. Her history indicated that after epistaxis had started, she went to the sink and cleaned her nose with water. She had pressed on her nose and called an ambulance. About 30 min after the start of epistaxis, an ambulance and emergency doctor arrived. The bleeding stopped while she was in the ambulance. Her blood pressure was 125/80 mmHg. She had an unremarkable past medical history and did not have coagulation diathesis or trauma/barotrauma, nor was she undergoing anticoagulant or salicylate therapy. She complained of slight hearing loss and a feeling of fullness in both ears. The physical examination was normal except for red-blue tympanic membranes and bilateral septal excoriation. There were no other petechiae or ecchymoses on the skin or mucous membranes. Her hematologic, biochemical and coagulation tests were also normal. Temporal bone fracture was ruled out by computed tomography scan.
Idiopathic or spontaneous hemotympanum is an uncommon disorder characterized by a black-blue tympanic membrane discoloration as a result of recurrent hemorrhage in the middle ear or mastoid in the presence of Eustachian tube obstruction. Initial evaluation of a blue middle ear mass includes an audiogram and computed tomography (CT) scan with intravenous contrast. CT may identify congenital vascular malformation or bone erosion due to chronic otitis media or tumors. A magnetic resonance imaging (MRI) scan is useful to distinguish hemotympanum from a vascular tumor and to avoiding angiography, which is associated with significant morbidity. Evidence suggests that secretory otitis media and spontaneous hemotympanum are different phases of the same disease process.
Epistaxis is common and occurs more commonly in male than female patients. Epistaxis is noted at higher incidence in older patients . It is secondary to local or systemic causes. Nasal trauma (surgical, digital), foreign bodies in the nasal passage, topical sprays or dust, inflammatory nasal diseases, septal deformities, tumors and vascular aneurysms can be the local factors [5, 6]. Coagulation deficits, Osler-Weber-Rendu disease and arteriosclerotic vascular diseases are possible systemic factors [5, 6]. Also regular uptake of anticoagulants can cause spontaneous bilateral hemotympanum .
The vascular supply of nasal mucosa originates from the external and internal carotid arteries. Kiesselbach's plexus, which is on the anterior part of the septum, is the site of most epistaxis events ; it is also known as Little's area and is rich in vascular supply .
Especially temporal bone fractures, nasal packing, anticoagulant therapy, chronic otitis media and coagulation deficits are the causes of hemotympanum [8–10]. It is most often associated with temporal traumas rather than nasal packing , but occasionally nasal packing, which can lead to peritubal lymphatic stasis, is a cause of hemotympanum . Dysfunction of the Eustachian tube is thought to be the reason for spontaneous hemotympanum secondary to epistaxis . In the case presented here, there was no history of nasal packing, so retrograde blood reflux to the Eustachian tube could have been the cause because there was a history of nasal pressure that could have caused reflux to the Eustachian tubes.
Computed tomography or magnetic resonance imaging is necessary for making the differential diagnosis concerning the etiology of epistaxis . In temporal traumas a fracture line could be visible on the scan, and chronic middle ear effusion can also be seen in cases of chronic otitis media. In patients with a basilar skull fracture, there can also be facial paralysis, tympanic membrane perforation or otorrhea. In patients with chronic otitis media, retraction pockets on the tympanic membrane are also visible.
All patients with hemotympanum need close follow-up. A fluid-filled middle ear cavity may result in conductive, sensorineural or mixed hearing loss . Not the type of fluid in the middle ear but rather the amount of fluid affects the rate of hearing loss . To prevent persistent effusion, physicians must treat the patient with antimicrobial drugs . The hearing deficits normalize after the middle ear effusion has been absorbed. Persistency of fluid may lead to permanent conductive hearing loss. Myringotomy with tube placement is needed for persistent effusions . All patients with hemotympanum must be followed up closely to ensure resolution.
Generally temporal bone fractures, nasal packing, anticoagulant therapy, chronic otitis media and coagulation deficits are the causes of hemotympanum. However, infrequently epistaxis is the causative factor. In patients with spontaneous hemotympanum secondary to epistaxis, emergency doctors need to work with otolaryngologists for close follow-up. Physicians must remember that to prevent long-term sequelae of persistent hemotympanum, myringotomy may be required.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
- Evans TC, Hecker J, Zaiser DK: Hemotympanums secondary to spontaneous epistaxis. J Emerg Med 1988, 6: 387–389. 10.1016/0736-4679(88)90011-XView ArticlePubMedGoogle Scholar
- Hurtado TR, Zeger WG: Hemotympanums secondary to spontaneous epistaxis in a 7-year-old. J Emerg Med 2004, 26: 61–63. 10.1016/j.jemermed.2003.05.001View ArticlePubMedGoogle Scholar
- Plaza G, Alvarez-Linera J, Galindo N: Cholesterol granuloma of the middle ear: cause of idiopathic hemotympanum. Acta Otorrinolaringol Esp 2000, 51: 724–728.PubMedGoogle Scholar
- Perretta LJ, Denslow BL, Brown CG: Emergency evaluation and management of epistaxis. Emerg Med Clin North Am 1987, 5: 265–277.PubMedGoogle Scholar
- Santamaria JP, Abrunzo TS: Ear, nose and throat disorders. In Pediatric emergency medicine: concepts and clinical practice. Edited by: Barkin RM, Caputo GL, Jaffee DM, Knapp JF, Schafermeyer RW, Seidel JS. Mosby, St. Louis, MO; 1997:713–716.Google Scholar
- Padgham N: Epistaxis: anatomical and clinical correlates. J Laryngol Otol 1990, 104: 308–311.View ArticlePubMedGoogle Scholar
- Balatsouras DG, Dimitropoulos P, Fassolis A, Kloutsos G, Economou NC, Korres S, Kaberos A: Bilateral spontaneous hemotympanum: case report. Head Face Med 2006, 4: 31. 10.1186/1746-160X-2-31View ArticleGoogle Scholar
- Hough JD, McGee MM: Otologic trauma. In Otolaryngology. 3rd edition. Edited by: Paparella MM, Shumrick DA. WB Saunders, Philadelphia, PA; 1991:1137–1160.Google Scholar
- Lalwani AK, Jackler RK: Spontaneous hemotympanum associated with chronic middle ear effusion. Am J Otol 1991, 12: 455–458.PubMedGoogle Scholar
- Pulec JL, DeGuine C: Hemotympanum from trauma. Ear Nose Throat J 2001, 80: 486–487.PubMedGoogle Scholar
- McCurdy JA Jr: Effects of nasal packing on Eustachian tube function. Arch Otolaryngol 1977, 103: 521–523.View ArticlePubMedGoogle Scholar
- Pulec JL, DeGuine C: Hemotympanum. Ear Nose Throat J 1996, 75: 66–68.PubMedGoogle Scholar
- Paparella MM, Jung TT, Goycoolea MV: Chronic middle ear effusion. In Otolaryngology. 3rd edition. Edited by: Paparella MM, Shumrick DA. WB Saunders, Philadelphia, PA; 1991:1335–1336.Google Scholar
- Bluestone CD, Klein JO: Intratemporal complications and sequelae of otitis media. In Pediatric otolaryngology. 3rd edition. Edited by: Bluestone CD, Stool SE, Kenna MA. WB Saunders, Philadelphia, PA; 1996:583–635.Google Scholar
- Healy GB: Antimicrobial therapy of chronic otitis media with effusions. Int J Pediatr Otorhinolaryngol 1984, 8: 13. 10.1016/S0165-5876(84)80021-XView ArticlePubMedGoogle Scholar
- Parisier SC, McGuirt WF: Injuries of the ear and the temporal bone. In Pediatric otolaryngology. 3rd edition. Edited by: Bluestone CD, Stool SE, Kenna MA. WB Saunders, Philadelphia, PA; 1996:700.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.