Abstract
Figure. Endoscopic views show the hemotympanum in the right (A) and left (B) ears.
A 40-year-old man with a long history of chronic nasal obstruction was referred to our hospital. The obstruction had been caused when he sustained nasal trauma 5 years earlier. In addition to breathing difficulty, the obstruction had caused sleep disturbance. The patient had frequently taken medications for relief of the obstruction, but he did not improve.
Nasal endoscopy revealed a severe deviation of the nasal septum to the right and hypertrophy of the left inferior turbinate. An allergic skin test was negative. The patient's medical history was unremarkable, and he had not recently taken any anticoagulant or salicylate medication. Findings on hematologic, biochemical, and coagulation testing were normal.
The patient underwent septoplasty and Coblation of the left inferior turbinate under general anesthesia. Despite nasal packing with several pieces of Vaseline gauze, he experienced massive epistaxis during the evening of the day of surgery. When we attempted to insert some more pieces of Vaseline gauze in the outpatient clinic, the patient experienced a brief period of syncope secondary to sudden transient hypotension. The epistaxis persisted after the syncope had resolved. The patient was returned to the operating room, and we controlled the bleeding with a suction coagulator without nasal packing. The source of the bleeding was identified as the posterior portion of the right inferior meatus.
Soon after the epistaxis resolved, the patient reported a slight hearing loss and a feeling of fullness in both ears. Otoscopy detected bilateral red-blue tympanic membranes (figure). Tympanometry yielded a type B (flat) result in both ears. Audiometry demonstrated mild bilateral conductive hearing loss. At follow-up 3 weeks later, otoscopy revealed that both tympanic membranes were mobile and normal in appearance. Audiometric evaluation showed hearing had returned to previous levels, and tympanometric findings were normal (type A).
Hemotympanum has many causes, including temporal bone fractures, barotrauma, administration of anticoagulants, hematologic disorders, and chronic otitis media secondary to the formation of granulation tissue or a cholesterol granuloma. 1 Hemotympanum secondary to nasal packing or spontaneous epistaxis has also been reported.1–3 Moreover, eustachian tube dysfunction has been proposed as a cause of this condition, with peritubal lymphatic stasis representing the most likely pathogenic mechanism. 4
In cases of epistaxis with or without nasal packing, blood can reflux into the middle ear via a patulous eustachian tube. Treatment of hemotympanum is usually conservative. Myringotomy and insertion of a ventilation tube may be needed for treatment when the condition persists beyond 1 month. 5 Most cases of hemotympanum resolve with no sequelae.