Myringotomy in traumatic haemotympanum

Myringotomy in traumatic haemotympanum

Report by Angaj Ghosh, Senior Clinical Fellow

Checked by Magnus Harrison, Richard Body, Clinical Research Fellows

Emergency Department, Manchester Royal Infirmary, Manchester, UK

Abstract

A short‐cut review was carried out to establish whether myringotomy is of value in cases of haemotympanum. In all, 205 papers were found in Medline and 105 in Cochrane using the reported searches. None presented any evidence to answer the clinical question. Hence, it is concluded that there is no evidence available to guide this decision and that local expert advice should be followed.

Clinical scenario

A 27‐year‐old man sustains punches on the face and ear during a drunken brawl. He attends the emergency department the next day with unilateral deafness and otalgia. Examination shows an intact tympanic membrane, but blood in the middle ear cleft. The senior health officer on‐call for ENT suggests that the patient needs a myringotomy to drain the blood. You wonder whether there is any evidence that this could relieve the symptoms and improve the outcome.

Three‐part question

In [an adult with a traumatic haemotympanum] is [myringotomy better than conservative management] at [improving hearing and relieving pain]?

Search strategy

Medline 1966–week 1 July 2006 using the OVID interface, and Cochrane Library Issue 2 2006. medline: [(exp wounds and injuries/or exp hemorrhage/or exp blood/or exp craniocerebral trauma/) or (injur$ or trauma$ or haemorrhag$ or hemorrhag$ or blood$ or bleed$).mp.] and (exp ear, middle/or exp tympanic membrane/or middle ear$.mp.) and [(exp middle ear ventilation/or exp drainage/) or (drain$ or myringotom$).mp.]. Cochrane Library: [exp MeSH descriptor tympanic membrane or exp MeSH descriptor ear, middle] and [myringotomy or drain*] and [injur* or trauma* or haemorrhag* or hemorhag* or bleed* or blood*].

Search outcome

Altogether 205 papers were identified using the reported Medline search and 105 papers in the Cochrane Library. None of the papers identified were relevant to the three‐part question.

Comments

Traumatic haemotympanum causes the tympanic membrane to appear dark blue, purplish or even almost black. It has traditionally been said to be pathognomonic of a temporal bone fracture. However, haemotympanum can also occur as a result of retrograde haemorrhage after epistaxis. It may be possible to gain some insight into the aetiology using colour as a guide. Haemotympanum secondary to epistaxis has been found to give a bright red appearance, perhaps signifying the presence of oxygenated blood (from the carotid arterial system, which supplies the nose) rather than deoxygenated blood (from venous bleeding associated with temporal bone fractures). This unproved technique may, however, be of questionable reliability.

There has been no published evaluation of myringotomy as a therapeutic technique in traumatic haemotympanum. Reports in the literature suggest that this condition may be treated conservatively. Prophylactic antibiotics are recommended, but a review of the evidence for this is beyond the scope of this BET.

Clinical bottom line

Patients with traumatic haemotympanum should be investigated for potential basal‐skull fracture. No published evidence is available of either benefit or harm with myringotomy, nor is there any evidence of harm after conservative management. Local advice should be followed.