Hemotympanum

The Wispr exam demonstrates mild bulging and hemotympanum as noted by the bloody-appearing middle ear fluid. The differential diagnosis for hemotympanum includes basilar skull fracture, hemorrhagic otitis media, and ruptured hemorrhagic bullae. However, this patient has no history of injury, ear pain, or fever to support such diagnoses. She does however have chronic liver disease—a risk factor for coagulopathy due to liver dysfunction and splenic sequestration of platelets. Given her physical exam findings and known need for platelet transfusions, the latter is likely the primary factor for her challenging epistaxis history.

Hemotympanum from epistaxis occurs when blood flows retrograde from the nasopharyngeal opening of the eustachian tube (ET) into the middle ear space. While retrograde flow is typically minimized by mucociliary action and a “physiologic valve” whereby the medial portion of the ET is collapsed (ie closed) in the resting state. The opening is controlled by several accessory muscles near the soft palate that are activated by swallowing or yawning and allows equalization of pressure (“clearing the ear, valsalva”). Likewise, nasal packing combined with brisk bleeding can overcome the tube’s protective measures and result in the accumulation of blood in the middle ear space. Here is another example of retrograde hemotympanum.

Both acute otitis media and middle ear effusion are middle ear conditions resulting from inflammation.

WiscMed appreciates the contribution of Dr. James Elliott of the University of Wisconsin for identifying this interesting case.

Szymanski A, Agarwal A. Anatomy, Head and Neck, Ear Eustachian Tube.