Bullous Myringitis in an Adult With Chronic Noise Exposure

Abstract

Bullous Myringitis (BM) is an acute painful infection in which vesicles or bullae form on the tympanic membrane. It is rare in adults and could be present with acute otitis media (AOM) if the middle ear is involved. This case report details a 55-year-old male with a history of recurrent childhood ear infections, chronic military noise exposure, smoking, and Crohn’s disease presenting with severe right ear pain, hearing loss, and fever. Examination revealed signs of AOM with perforations in the tympanic membrane and purulent drainage. Initial management included antibiotics and analgesics, but symptoms progressed, requiring further investigation. Imaging showed complete opacification of the R ear structures without bone erosion. Despite initial treatment, the patient’s condition worsened with bilateral hearing loss and intermittent peripheral vertigo. Ear, nose and throat (ENT) consultation and advanced diagnostics led to a diagnosis of BM with AOM, and asymmetric sensorineural hearing loss. The treatment was escalated to include high-dose steroids, azithromycin, valacyclovir, and daily aspiration of effusion. His symptoms improved, and he was discharged with oral antibiotics and scheduled follow-up. This case highlights the complexity of diagnosing BM that complicates AOM in an adult and the importance of detailed history, underlying past medical conditions pertinent to early diagnosis, consideration of less common pathogens, and comprehensive treatment.

1. Introduction

Bullous Myringitis is an acute painful infection in which vesicles or bullae form on the tympanic membrane.1 It is common in males less than 8 years old. It can also present with AOM when the middle ear is involved (Table 1). BM can be caused by respiratory viruses like Respiratory syncytial virus, and respiratory bacteria such as Hemophilus influenzae, Streptococcus pneumoniae, Mycoplasma pneumoniae, and Moraxella catarrhalis, or following respiratory tract infections. These pathologic organisms are also implicated in AOM. BM is associated with recurrent ear infections, trauma, and sudden loud noises. Diagnosing both BM and AOM in an adult require detailed history, physical examination, and a high degree of suspicion. This case report details the presentation, and management of a 55-year-old male with a history of recurrent childhood ear infections, chronic military noise exposure, smoking, and Crohn’s disease on immunosuppressants presenting with severe right ear symptoms and hearing loss, and a diagnosis atypical for his age demographic.

Table 1.

Differentiating Bullous Myringitis from acute otitis media.

	Bullous Myringitis	Acute Otitis Media
Common causes	Likely viral respiratory infections	Viral and Bacterial respiratory infections
Primary area affected	Tympanic Membrane	Middle ear
Fever	Possible, not always present	Often present
Pain	Usually severe and localized to the eardrum	Variable mild to moderate
Hearing loss	Muffled or reduced hearing due to blister formation on the tympanic membrane	Conductive hearing loss from fluid buildup in the middle ear
Tympanic membrane	Blisters, bullae, or vesicles on the tympanic membrane	Bulging, erythematous, opaque, or cloudy, fluid filled membrane
Tympanic membrane mobility	Reduced or absent mobility due to blisters	Reduced or absent mobility due to fluid in the middle ear

2. Case presentation

A 55-year-old male presented to the emergency room with a 5-day history of severe right ear pain with intermittent yellowish discharge. His symptoms began following episodes of sneezing and coughing. The pain was throbbing and severe, radiating to the right temporal region. He also reported decreased hearing, short-interval vertigo (5–10 s per episode), and fevers ranging from 101.2 °F to 103.2 °F. His medical history included recurrent ear infections in childhood, requiring bilateral tympanostomy tubes until early adulthood.

On physical examination, the patient appeared drowsy. The right ear examination revealed yellowish crusting with purulent drainage from the external auditory canal (EAC), retro auricular fullness, and minimal tragal tenderness. The pinna was proptotic with erythema, the mastoid was erythematous and tender. The tympanic membrane exhibited small perforation in the posterosuperior quadrant and a linear perforation in the anterior inferior quadrant, both draining serous fluid. The left ear examination was unremarkable.

Initial management included a computed tomography scan (Fig. 1), which demonstrated complete opacification of the right EAC, mastoid, and middle ear without bone erosion or sigmoid sinus thrombosis. White count levels were normal. The patient was started on oral ampicillin-sulbactam, topical ciprofloxacin, and oral analgesics, with tympanocentesis and subsequent ear cultures being obtained prior to antibiotic administration.

Fig. 1.

Computed tomography (CT) with IV contrast of the internal auditory canal.

By the third hospital day, symptoms progressively worsened and spread to the left ear. Examination revealed bilateral postauricular tenderness and erythema, more pronounced on the right side, with active and dried yellow discharge. The right tympanic membrane was occluded by discharge and the patient experienced severe pain. Audiometric testing indicated profound sensorineural hearing loss in the right ear and mild to moderate sensorineural hearing loss in the left ear.

ENT review and detailed examination including pneumatic otoscopy, tympanometry, and acoustic reflectometry showed bullae and vesicles on the tympanic membrane; Magnetic Resonance Imaging (Fig. 2) showed soft tissue thickening of the right auditory canal and he was diagnosed with non-hemorrhagic BM and AOM of the right ear and asymmetric sensorineural hearing loss. The left ear was diagnosed AOM with effusion. Ear abscess cultures grew Dermobacter hominis, Corynebacterium amycolatum and Staphylococci capitis, hominis, pettenkoferi, and epidermidis all resistant to ampicillin-sulbactam.

Fig. 2.

Magnetic resonance imaging of the internal auditory canal done 1 week later.

Treatment was escalated to high-dose oral prednisone, azithromycin for potential mycoplasma infection, valacyclovir for possible Ramsay Hunt syndrome, and daily aspiration of effusion. Following 2 days of this treatment plan, the patient’s pain and discharge decreased, with minor improvement in his hearing on the left. Once he was stabilized for discharge 2 days later, he had complete resolution of hearing loss on his left. Per infectious disease recommendation, he was discharged with oral linezolid 600 mg twice a day and Augmentin 875/125 mg twice a day for two weeks, with a follow-up outpatient appointment with the ENT specialist.

3. Discussion

This case features the complexity of diagnosing BM in an adult with AOM complicated by sensorineural hearing loss (Table 1). BM in adult males is rare, and its symptoms are very similar to AOM, and can also present concurrently. BM is not usually the first differential diagnosis in adult male population like our patient but his co-morbidities like recurrent ear infections and instrumentation, chronic noise exposure, immunocompromised state, and smoking may have predisposed him to this rare disease.

BM is classically characterized by painful bullae and/or vesicles limited to the tympanic membrane.1 Common microorganisms include Streptococcus pneumoniae and Mycoplasma pneumoniae, with common viral causes being Respiratory Syncytial Virus (RSV) and influenza.1 His viral panel was negative and ear cultures in this patient instead revealed Corynebacterium amycolatum2 and Staphylococci capitis, unusual pathogens for this condition but plausible given his clinical deterioration.

The pathophysiology of BM is similar to that of AOM, although there is still some uncertainty about its overall pathologic process.1 Tympanic membrane irritation limited to the middle ear, occurring secondary to trauma, sudden loud noises, changes in airway pressure with repeat insult likely causes bullae and/or vesicles to form. Regarding bacterial, viral, and fungal causes, it is likely that the spread of infection from surrounding ear structures to the tympanic membrane causes an inflammatory process that also forms bullae and/or vesicles. The interchangeability of AOM with concurrent BM is also present and either one increases the risk for the other.1 Although commonly diagnosed in children (1 in 20 cases following AOM), the incidence of BM in adults remains undetermined, but incredibly rare due to a relative lack of studies in the literature describing the condition in adults.3

The patient’s smoking history and prolonged exposure to loud noises likely contributed to the severity and susceptibility of his ear condition.1 Additionally, his history of Crohn’s disease may have predisposed him to infections due to a potentially compromised immune system. The initial treatment with broad-spectrum antibiotics and analgesics was appropriate, but the persistence of symptoms and involvement of the contralateral ear necessitated further intervention with high-dose steroids and antivirals. Audiometric findings showed profound sensorineural hearing loss in the right ear and mild to moderate sensorineural hearing loss in the left ear, which is not uncommon in BM.4 Patient’s course may suggest the nose as the portal of entry and then spreading to the middle ear outwards. The addition of prednisone aimed to reduce inflammation although the patient did not regain his hearing on his right ear as he did on the left ear, The role of steroids in recovering hearing loss is still debatable. 5 Perhaps with an earlier diagnosis and intervention, the right hearing loss would have been transient,5 although the longer duration of symptoms in the right ear may have contributed to the persistent hearing loss.

4. Conclusion

This case highlights the importance of recognizing and aggressively managing BM in patients presenting with signs and symptoms of AOM especially if these patients have comorbidities that could predisposed them to BM. Early and accurate diagnosis of BM matters because when misdiagnosed as AOM only, the initial approach is not as aggressive and timely as BM requires to prevent persistent or recurrent pathologies. Despite appropriate and escalated treatment, the patient’s hearing loss persisted at discharge, emphasizing the need for broader differentials and early diagnosis. The case also highlights the potential role of less common pathogens and underlying health conditions in the pathogenesis of complex ear infections.