Understanding Myringitis: Types, Symptoms, and Treatment

Inflammation of the tympanic membrane.

Types of Myringitis

1. Acute bullous myringitis
2. Granular myringitis

Acute Bullous Myringitis

• Bullous myringitis is an acute inflammatory condition affecting the tympanic membrane.
• Hallmark of bullous myringitis: Presence of bullae or vesicle on the surface of TM
• Previously, it was thought to be primarily caused by viruses or mycoplasma, but the latest edition of Scott-Brown states that acute myringitis is typically due to bacterial infections, especially Streptococcus pneumonia. While viral factors, H. influenzae, and mycoplasma have been considered causative agents, Streptococcus pneumonia is the most common organism responsible.
• Bullae may be single or multiple, and they may be limited to one quadrant/segment or involve all quadrants of the tympanic membrane. Occasionally, the external auditory canal can also be affected.

Pathology 

The inflammation can be triggered by various factors, including infective agents (bacteria or viruses), thermal changes in the canal (such as cold or warm currents), or underlying immunosuppression of the patient.

Infective agents cause the release of serous fluid between the middle fibrous layer and the outer squamosal layer of the tympanic membrane, leading to the formation of vesicles.

Also read: Keratosis Obturans, ACC, and BNOE: Overview &Treatment 

Aetiology

Streptococcus pneumonia: Most common

Other possible causative agents include

• Haemophilus influenzae
• Beta-hemolytic streptococci
• Moraxella catarrhalis
• Various respiratory viruses, such as rhinovirus, enterovirus, respiratory syncytial virus, influenza A, and parainfluenza virus

Epidemiology

1. This condition is commonly observed during the winter months.
2. It can be associated with middle ear disease.
3. Acute bullous myringitis is most prevalent in individuals aged 2–8 years.
4. Symptoms of acute otitis media and acute bullous myringitis can overlap, including pain, fever, and hearing loss.

Presentation

• Diagnosis is based on a patient's history and clinical examination.
• Typically, patients present with a sudden onset of severe otalgia, often unilateral and associated with an upper respiratory tract infection.
• Pain may last only 1-2 days but discomfort may persist for longer even after rupture of the bullae

Otoscopy Findings

• Otoscopy reveals the presence of bullae on the tympanic membrane.
• Rupture of the bullae may lead to scanty serosanguinous otorrhea, which is usually short-lived due to a lack of membrane proliferation.
• Middle ear effusion can cause conductive hearing loss.
• Sometimes, mixed or sensorineural hearing loss may occur.
• A large single bulla arising from the posterior aspect of the left tympanic membrane
• Sensorineural hearing loss is a rare occurrence, with a prevalence of 15–66%.
• Complete recovery of hearing is observed in 57-100% of cases, irrespective of treatment.
• The pathogenesis of SNHL in BM is unknown but stapedial reflexes and auditory brainstem responses have implicated the cochlea as the site of the lesion

Also read: Adenoid And Adenoidectomy 

Vertigo in Bullous Maryngitis

1. Approximately 54% of patients reported vertigo at presentation.
2. Sensorineural hearing loss is observed in 82% of the cases.
3. The cause of vertigo is unclear, but it may be related to inflammatory changes in the labyrinth, vestibule, or semicircular canal, resulting in transient vertigo.

Treatment 

• Acute bullous myringitis is typically a self-limiting disease with spontaneous resolution of symptoms.
• Symptomatic treatment may include analgesics (topical/systemic), warm compressions, and incision of the bullae.
• In cases where the inner ear is involved, more aggressive treatment with broad-spectrum oral antibiotics may be considered.
• Sudden onset sensorineural hearing loss is treated with high-dose steroids.

Granular Myringitis

Granular myringitis is characterized as a chronic inflammatory disorder that involves the de-epithelialization of the outer (squamous) layer of the tympanic membrane. This layer is replaced with granulation tissue, and notably, this condition occurs in the absence of middle ear disease.

Clinically, this condition may be defined as persistent inflammation confined to squamous layer of the TM for at least 12 weeks

Pathology 

Histological examination reveals oedematous granulation tissue with capillaries and diffuse infiltration of chronic inflammatory cells.

Aetiology 

The development of granular myringitis is associated with non-specific injuries, such as trauma or infection, which hinder epithelialization and promote the formation of granulation tissue.

Common causative organisms include:

• Pseudomonas aeruginosa
• Staphylococcus aureus (including MRSA)
• Corynebacterium
• Proteus mirabilis
• Various fungal species.

Also read: Benign Paroxysmal Positional Vertigo (BPPV)

Clinical Presentation 

• Permanent or recurrent painless otorrhea, which can sometimes have a foul odor.
• Diagnostic Evaluation: A CT scan, X-ray, or microscopic examination may be required to rule out conditions like Chronic Suppurative Otitis Media (CSOM) or Cholesteatoma, which can have similar symptoms.
• Intrameatal Itch or Fullness
• Mild Conductive Hearing Loss
• Rare Otalgia: Although not common, some patients may experience ear pain.
• Some patients may be Asymptomatic

Otoscopy Findings 

1. Granular myringitis is characterized by the presence of granulation tissue or polyps, which replace the normal squamous epithelium on the tympanic membrane.
2. In some cases, the tympanic membrane may also appear thickened.
3. Granulation can be localized to part of the TM (focal/segmental) or diffuse
4. The segmental type is more common, with the posterosuperior segment of the eardrum most frequently affected. It may also involve the skin of the adjacent medial ear canal.
5. Differential Diagnosis: During otoscopy, it is crucial to rule out tubercular otitis media (TBOM) and other conditions.
6. Pain is not one of the characteristic features of granular myringitis.

Investigations

• A swab should be taken for microscopy, culture, and sensibilities. This helps identify the causative microorganism and its susceptibility to antibiotics, guiding antimicrobial treatment.
• Depending on the results of the swab, systemic or topical antibiotics are often prescribed as part of the treatment plan.
• Pure Tone Audiometry and Tympanometry: These tests are conducted to assess hearing loss or identify any potential middle ear pathology.
• In certain cases, a CT scan of the temporal bone may be necessary to exclude underlying middle ear or mastoid disease.
• A biopsy may be considered if there are concerning features, such as significant otalgia (ear pain) or non-resolution of symptoms despite treatment. This is done to rule out malignancy, which is a rare but important consideration.

Also read: Granulomatous Conditions of the Nose 

Complications

Prolonged or severe cases of granular myringitis can lead to fibrosis, scarring, and stenosis of the middle ear canal with lateralization of the eardrum, where the eardrum is pulled to one side.

Otorrhea may not resolve; it often leads to significant conductive hearing loss.

Treatment 

1. Microscopic cleaning and debridement, along with the application of topical antibiotics or antiseptic agents along with antifungals, forms the mainstay of initial management.
2. Treatment is often more prolonged than for other types of otitis, and recurrence is relatively common.
3. Topical antibiotics and antifungals, often with a steroid/anti-inflammatory agent, can be given.
4. Topical antiseptic agents: acetic acid, aluminium acetate, phenol, and hydrogen peroxide can be given to make the canal clean without granulations
5. Granulation tissue is often managed by debulking, which involves the removal of excess tissue. This can be done using various techniques, including cold steel (curettage or cupped forceps), silver nitrate cautery, or laser debridement/resurfacing.
6. Surgical excision with grafting can involve the removal of granulation tissue, and skin grafts or the temporalis fascia/perichondrium underlay technique may be employed to promote healing and reduce the risk of recurrence.
7. Topical antibiotics and antifungals, often with a steroid or anti-inflammatory agent
8. Topical antiseptic agents: acetic acid, aluminium acetate, phenol, hydrogen peroxide.

Also read: Middle Ear Implant : Transducer, Vibroplasty 

FAQ’S

Q. What are the complications for myringitis?

Ans. If untreated, myringitis may lead to ear drum perforation and hearing loss

Q. How do I prevent myringitis?

Ans. Avoid exposure to smoke & dust, and avoid excess ear moisture.

Download the PrepLadder app now to access high-yield content with 24-hr Free Trial. Explore premium study resources like Video Lectures, digital notes, QBank, and Mock Tests for a seamless exam preparation. Start your ENT Reasidency coaching journey with PrepLadder.