Myringitis (Middle Ear, Tympanic Membrane, Inflammation) Clinical Presentation

Updated: Oct 20, 2017
  • Author: John Schweinfurth, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Presentation

History

Generally, the patient presents with a 2- to 3-day history of ear congestion and mild hearing loss. Patients often have a history of self-cleaning of the EAC, trauma, or penetration of water into the EAC. Sensations of heaviness and slight pain in the ear are common. Sometimes an itch is present in the EAC, or discharge from it is noted.

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Physical

The TM has long been recognized as the true mirror of the middle ear, with all its changes reflected on the surface of the TM. In the case of AOM, examining the changes related to all stages of inflammation on the surface of the TM is possible. Otoscopy allows examination of the tensed grey-blue membrane with reflected light directed into the lower front section. The TM has identifiable items, such as the light reflect, the umbo, the handle of the malleus, the lateral process of the malleus, the lenticular process of the incus, and the anterior and posterior plicae of the TM.

Typical otoscopic examination results are as follows:

  • In cases of acute myringitis, the TM is evidently altered by the inflammatory process; it is red and deformed, and the light reflex is shortened or disappears completely.

  • Acute hemorrhagic myringitis can be the consequence of a bacterial infection such as S pneumoniae or a viral infection. Differential diagnoses for a red tympanic membrane are widely varied and include malformations, traumas, infections, and even tumors and other degenerative pathologies.

  • Acute bullous myringitis can also be the consequence of a bacterial or viral infection.

  • Myringitis granulosa, when the TM is covered with granulation tissue, may be observed.

  • When acute otitis has resolved, recognizing perforations of the TM is possible. These perforations are characterized by scarring (myringosclerosis) and areas of calcification.

  • In cases of chronic myringitis, the TM is perforated, with inflamed edges and granulation tissue.

  • Hearing loss may be noted.

  • Discharge from the EAC is present in some cases.

  • Some children experience pain upon traction of the pinna.

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Causes

Determining the cause of the TM inflammation is important to treat both it and the accompanying and subsequent processes of otitis media and external otitis.

Bacterial causes of TM inflammation include the following:

  • Staphylococcus pyogenes and Staphylococcus aureus

  • Escherichia coli and Klebsiella species

  • S aureus and Streptococcus epidermidis

  • Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis (causes of about 70% of cases) - In a pooled analysis of 10 observational studies of children aged 3 months to 5 years with AOM, Van Dyke et al found that severe TM inflammation was more likely to be a presenting symptom in cases that were positive for H influenzae than in those that were positive for S pneumoniae [3]

  • Bacillus fragilis and Peptostreptococcus species

  • Pseudomonas aeruginosa, Proteus mirabilis, and S aureus

  • Mycoplasma pneumoniae (bullous myringitis)

  • Trichophyton rubrum in the external auditory meatus

  • Mycobacterium tuberculosis

  • Corynebacterium species - A retrospective study of cultures from adult and pediatric patients who presented with purulent and mucopurulent otologic infections found corynebacteria in 24 patients (33.3%), with a significant relationship indicated between Corynebacterium-positive infections and the presence of chronic granular myringitis [4]

Other causes include the following:

  • Fungal infection

  • Viral infection (eg, herpes zoster, influenza)

  • Eczematous otitis externa, which can cause eczematous myringitis

  • Granulation tissue covering the TM

  • Extra-esophageal reflux [2]

  • Chronic myringitis, which is often accompanied by chronic inflammation of the middle ear or the EAC (Chronic myringitis is often mistaken for chronic otitis media. Such confusion prolongs the initiation of appropriate management and sometimes leads to needless tympanomastoid surgery. The ENT specialist should be aware of this clinical entity and its varied presentation.)

  • Chronic inflammation of the TM with perforation, which may also occur as a result of a condition developing at the junction between the skin and the mucous membrane (Retraction of the TM is clinically important because failure to do so is a possible cause of atelectasis, ossicular erosion, and cholesteatoma.)

For more information, see Otitis Media, External Ear, Infections, External Ear, Malignant External Otitis, and External Ear, Inflammatory Diseases.

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