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Infectious Myringitis
ALTERNATIVE NAMES: Acute otitis media, acute myringitis, bullous myringitis.
DEFINITION: Acute inflammation of the tympanic membrane (eardrum).
WHAT IS GOING ON IN MY BODY? The eardrum is a three-layered structure. The layer facing the ear canal is lined by a very thin layer of skin. The layer on the other side of the eardrum is mucous membrane identical to that which lines the rest of the middle ear, mastoid, and eustachian tube. In between these two layers is a tough layer that provides the major structural integrity of the eardrum. Any infectious process of the middle ear or external ear can lead to inflammation of the tympanic membrane. There can be direct eardrum infections where it can be affected by inflammation in the middle ear or the external canal. Often the very earliest finding in an acute otitis media is an intense inflammation of the tympanic membrane. A variant of infectious myringitis is bullous myringitis, whereby blisters form on the drum. In the past it was thought that this was secondary to bacteria called mycoplasma, but clearly most forms of bullous or infectious myringitis are caused by the typical bacteria that cause acute otitis media. These would include Strep pneumonia, Hemophilus influenza, and Moraxella catarrhalis. Viruses that attack mucous membrane can certainly cause an infectious myringitis, such as adenovirus, rhinovirus, coxsackie virus, influenza, and parainfluenza viruses. In the case of external canal infection causing myringitis, these bacteria are usually Pseudomonas aeruginosa or Staph aureus. Rarely tuberculosis can cause an eardrum infection and is characterized by multiple small perforations in the drum. Chronic myringitis can also occur usually from pseudomonas.
WHAT ARE THE SIGNS AND SYMPTOMS? The most significant symptom in infectious myringitis is ear pain. Because of infection of the eardrum, there may also be fever and hearing loss. In situations where blisters form on the eardrum and then rupture, there may be bloody and infected-looking material draining from the ear canal. If the myringitis is a result of an infection in the ear canal, there is often significant tenderness around the opening to the ear canal and infected draining material. On examination in a pure primary infectious myringitis, the tympanic membrane is often intensely red with increased prominence of the small blood vessels that perfuse the tympanic membrane. There may be inflammation of the lining of the middle ear. If it is a result of an acute otitis media, there may be infected material or fluid behind the eardrum. If the myringitis is from an external canal infection, then intense swelling and tenderness will be present along with purulent visible debris in the external canal. Chronic myringitis usually has a granular, red tissue on the drum surface covered by infected material.
WHAT ARE THE CAUSES AND RISKS? As mentioned above, the main causes would be a primary viral or bacterial infection of the eardrum. The eardrum can also be affected secondarily by an acute otitis media or an acute otitis externs (swimmer's ear). The main risks of acute myringitis would be perforation of the tympanic membrane or significant scarring of the eardrum that could result in hearing loss.
HOW TO PREVENT THE DISEASE: Certainly measures taken to reduce the spread of viral illness would be helpful, such as avoiding ill individuals, daycare environments, crowded living conditions, and hand washing. In children suffering from acute otitis media, the pneumonia vaccine (pneumovax) and flu vaccination may help prevent the acute otitis media. Preventing the external canal infection largely depends upon keeping the ear canal dry.
HOW IS IT DIAGNOSED? It is predominantly diagnosed based upon physical examination and identification of an intensely inflamed tympanic membrane, blisters on the drum, or granular tissue on its surface.
WHAT ARE THE LONG-TERM EFFECTS? If it is viral, there may be some very mild thickening and scarring of the tympanic membrane that should have little, if any, effect upon hearing. If the eardrum perforates, most of these close spontaneously, although the ones that do not may require later surgical repair.
AM I PUTTING OTHERS AT RISK? No.
WHAT ARE THE TREATMENTS? If it is a purely viral form of infectious myringitis, then it will resolve spontaneously. Use of ear canal anesthetics or oral analgesics will enhance patient comfort. If an acute otitis media develops or the infectious myringitis is bacterial in nature, then oral antibiotics are the mainstay of therapy. For individuals with acute external canal infections, the main means of treatment is using antibiotic and steroid ear drops. In more severe cases, potent analgesics and broad-spectrum oral antibiotics may be useful. Chronic myringitis treatment involves antibiotic ear drops but may respond to acetic acid ear canal irrigations followed by application of steroid cream.
WHAT ARE THE SIDE EFFECTS TO THE TREATMENTS? The main side effects would be those specific to the various medications employed.
WHAT HAPPENS AFTER TREATMENT? After successful treatment, the eardrum should return to its normal status.
HOW DO I MONITOR THE DISEASE? Since the main symptom is pain, unrelenting pain is an indication of progression of the inflammatory process. Should it not resolve over a brief observation period, then medical attention needs to be delivered. Persistent drainage or hearing loss should also be investigated.
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