Bullous Myringitis: Symptoms, Types, Causes and Treatment

Bullous myringitis is a distinct yet often misunderstood ear condition characterized by the sudden appearance of fluid-filled blisters on the tympanic membrane (eardrum). While it shares much in common with acute otitis media (AOM), bullous myringitis can cause more intense symptoms and occasionally leads to complications such as hearing loss. Understanding its symptoms, variations, underlying causes, and evidence-based treatment options is essential for patients, caregivers, and clinicians alike.

Symptoms of Bullous Myringitis

Bullous myringitis frequently presents with a striking and distressing set of symptoms, especially in young children and adults. The rapid onset and severity often set it apart from other ear infections, making early recognition key for prompt management.

Symptom	Prevalence	Notable Features	Source(s)
Ear pain	Sudden, severe	More intense than AOM	1, 2
Fever	62% in children	Often ≥38°C	1
Ear blisters	Common	Vesicles on eardrum	2, 7, 8
Hearing loss	Mixed/sn loss	Often reversible, variable	2, 3
URI symptoms	73–93%	Rhinitis, cough	1
Irritability	Common in kids	Excessive crying, poor sleep	1

Table 1: Key Symptoms

Sudden and Severe Ear Pain

The hallmark of bullous myringitis is a rapid onset of intense ear pain (otalgia). This pain is typically more pronounced than that experienced in standard acute otitis media. In adults and older children, the pain can be described as sharp and severe, often prompting urgent medical attention. In infants and toddlers, the pain may manifest as increased irritability, excessive crying, or frequent tugging at the affected ear 1, 2.

Fever and Systemic Symptoms

Fever is present in over half of pediatric cases, often exceeding 38°C (100.4°F). This systemic response can be accompanied by other general symptoms such as malaise, poor appetite, and restless sleep. These symptoms tend to be more marked in bullous myringitis compared to non-bullous acute otitis media 1.

Vesicles on the Tympanic Membrane

A defining feature of bullous myringitis is the presence of fluid-filled blisters or vesicles on the tympanic membrane and sometimes the adjacent ear canal wall. These blisters may rupture, occasionally leading to a bloody or watery discharge from the ear 2, 7, 8. Their appearance is a key diagnostic clue.

Hearing Loss

Hearing loss, which may be conductive, sensorineural, or mixed, is common in bullous myringitis. It often resolves as the condition improves, but can range from slight to severe and affect high frequencies in particular. Early audiometric evaluation is advised, especially when hearing loss is reported 2, 3.

Associated Upper Respiratory Infection (URI) Symptoms

Most cases are preceded or accompanied by upper respiratory tract infection symptoms such as runny nose (rhinitis) and cough. These symptoms are present in the majority of pediatric cases, reflecting the close association between bullous myringitis and respiratory infections 1, 2.

Additional Pediatric Symptoms

In infants and young children, the symptom profile may include:

• Excessive crying
• Poor appetite
• Ear rubbing/tugging
• Restless sleep

These signs are more frequently observed in bullous myringitis than in typical AOM 1.

Types of Bullous Myringitis

While bullous myringitis is generally defined by the presence of blisters on the eardrum, clinical observations have led to the identification of several subtypes, primarily based on the nature of the blisters and associated findings.

Type	Description	Common Group	Source(s)
Bullous	Clear or serous blisters	All ages	1, 7, 8
Hemorrhagic	Blood-filled blisters	Children	5, 6
Unilateral	One ear affected	Majority	3
Bilateral	Both ears affected	Minority	3

Table 2: Types of Bullous Myringitis

Bullous (Serous) Myringitis

The classic form involves the formation of translucent, fluid-filled vesicles on the tympanic membrane. These blisters may be clear or yellowish and are the most common presentation in both children and adults 1, 7, 8.

Hemorrhagic Myringitis

Some cases, particularly in children, present with hemorrhagic (blood-filled) blisters. These may rupture and lead to blood-tinged ear discharge. Hemorrhagic myringitis is less common than the serous type but follows a similar clinical course and is managed similarly 5, 6.

Unilateral vs. Bilateral Involvement

Bullous myringitis most frequently affects only one ear (unilateral), but bilateral cases do occur, representing about 16% of cases in some adult series 3. The severity and symptom profile do not differ significantly between unilateral and bilateral cases.

Relationship to Acute Otitis Media

Many researchers now consider bullous myringitis not as a separate disease but as a variant of acute otitis media with the additional finding of blisters on the eardrum. Virtually all pediatric cases have concomitant middle ear fluid, indicating middle ear involvement 1, 5, 8.

Causes of Bullous Myringitis

The root causes of bullous myringitis have been debated for decades. While once thought to be viral or linked to Mycoplasma pneumoniae, more recent evidence points strongly toward bacterial pathogens, with a pattern similar to that seen in acute otitis media.

Cause	Prevalence/Role	Notes	Source(s)
Bacterial	Most common	S. pneumoniae, H. influenzae	4, 5, 8
Viral	Possible, not primary	No specific virus implicated	6, 7, 8
Mycoplasma	Rare, unproven	Very few documented cases	2, 4, 8
Middle ear disease	Strongly associated	>95% have middle ear fluid	1, 5, 8

Table 3: Causes of Bullous Myringitis

Bacterial Etiology

• Streptococcus pneumoniae is the leading bacterial cause, followed by Haemophilus influenzae and beta-hemolytic Streptococcus. This mirrors the microbial profile seen in acute otitis media, but with an even higher proportion of S. pneumoniae in bullous and hemorrhagic cases 4, 5, 8.
• Middle ear fluid in affected children almost always yields these typical bacteria, emphasizing the close association with AOM 1, 5.

Viral and Mycoplasmal Theories

• While early studies speculated that viruses (such as influenza or adenovirus) or Mycoplasma pneumoniae might be the main culprits, large studies have failed to confirm a consistent viral or mycoplasmal etiology 2, 4, 6, 7, 8.
• Respiratory viruses are frequently found in nasopharyngeal samples from children with bullous myringitis, but their presence does not prove causality, and no specific virus has been definitively linked to the condition 6.
• Mycoplasma pneumoniae is rarely isolated in cases of bullous myringitis or otitis media, and current evidence does not support it as a major pathogen 2, 4, 8.

Association with Middle Ear Disease

• Over 95% of cases of bullous myringitis in children are associated with middle ear effusion (fluid), indicating that bullous myringitis is almost always a manifestation of acute otitis media with blister formation on the eardrum 1, 5, 8.

Treatment of Bullous Myringitis

Treatment strategies for bullous myringitis largely mirror those for acute otitis media, given their shared bacterial causes and clinical overlap. However, management must also address the risk of hearing loss and the intensity of symptoms.

Treatment	Indication	Effectiveness/Outcome	Source(s)
Antibiotics	Mainstay (esp. children)	Rapid symptom relief	1, 5, 8
Pain management	All patients	Relieves severe otalgia	1, 2
Steroids	For hearing loss (debated)	No proven added benefit	9
Audiometry	If hearing loss present	Detects/mons hearing loss	3
Monitoring	All cases	Most resolve in 1–2 days	1, 2

Table 4: Treatment Approaches

Antibiotic Therapy

• First-line treatment: Antibiotics are recommended, especially in young children, due to the high likelihood of bacterial involvement. Most experts advise treating bullous myringitis as acute otitis media 1, 5, 8.
• Antibiotic choice: Amoxicillin is often first-line, but the choice may be tailored based on local resistance patterns and clinical judgment.

Pain Management

• Analgesics: Addressing pain is crucial, given the severe otalgia associated with bullous myringitis. Acetaminophen or ibuprofen are commonly used and should be given as needed for comfort 1, 2.
• Blister rupture: If blisters rupture, they may drain serous or bloody fluid. This is generally self-limited and does not require specific intervention beyond keeping the ear dry.

Management of Hearing Loss

• Audiometric evaluation: Early hearing testing is advised in cases with reported hearing loss. Most hearing deficits are reversible and resolve as the infection clears, but some may persist or affect high frequencies 3.
• Steroid use: Systemic steroids are sometimes prescribed for sensorineural hearing loss, but recent studies show that adding steroids to antibiotics does not improve hearing recovery compared to antibiotics alone 9.

Monitoring and Follow-Up

• Rapid resolution: Most cases resolve within 1–2 days with appropriate therapy, and the prognosis is excellent 1, 2.
• Follow-up: Repeat ear examination and hearing assessment (when indicated) ensure full recovery and help detect rare complications.

When to Seek Specialist Care

• Persistent or severe hearing loss
• Recurrent episodes
• Failure to improve within 48–72 hours
• Signs of complications (e.g., severe dizziness, facial weakness)

Conclusion

Bullous myringitis is an acute ear condition marked by blisters on the eardrum, severe pain, and often a rapid but dramatic course. Its close relationship with acute otitis media guides both diagnosis and treatment. Here’s a summary of the key takeaways:

• Symptoms: Sudden, severe ear pain, fever, hearing loss, and blistering of the eardrum are characteristic, with more pronounced symptoms than typical otitis media 1, 2, 3.
• Types: Includes bullous (serous), hemorrhagic, unilateral, and bilateral forms; usually coexists with middle ear effusion 1, 3, 5.
• Causes: Most often due to common otitis media bacteria (especially S. pneumoniae); viruses and Mycoplasma are rarely primary causes 4, 5, 6, 8.
• Treatment: Treat as acute otitis media with antibiotics and pain relief; steroids are not routinely beneficial for hearing loss; most cases resolve quickly with proper management 1, 5, 8, 9.

By recognizing its symptoms, understanding its causes, and applying evidence-based treatment, bullous myringitis can be managed effectively, minimizing discomfort and reducing the risk of complications.