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Three Part Question

In [an adult with a traumatic haemotympanum] is [myringotomy] going to [improve hearing and relieve pain]

Clinical Scenario

A 27 year-old man sustains punches to the face and ear during a drunken brawl. He attends the Emergency Department the next day complaining of unilateral deafness and otalgia. Examination reveals an intact tympanic membrane but blood in the middle ear cleft. The SHO on-call for ENT suggests he needs a myringotomy to drain the blood. You wonder whether there is any evidence that this could relieve symptoms and improve outcome.

Search Strategy

Medline using BMA OVID interface, 1966 to 2006 July Week 1.
The Cochrane Library 2006 Issue 2
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: [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 Cochrane. None of the papers identified were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

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 (Deguine and Pulec, 2003; Pulec and Deguine, 2001). However, haemotympanum can also occur as a result of retrograde haemorrhage following epistaxis (Evans et al, 1988). 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 de-oxygenated blood (from venous bleeding associated with temporal bone fractures) (Huff and Weimerskirch, 1989). This unproven 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 (Deguine and Pulec, 2003; Pulec and Deguine, 2001). 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. There is no published evidence of either benefit or harm with myringotomy, nor is there any evidence of harm following conservative management. Local advice should be followed.

References

1. Deguine C; Pulec JL Temporal bone fracture with hemotympanum Ear, Nose and Throat Journal 2003; 82(12): 903
2. Pulec JL; Deguine C. Hemotympanum from trauma Ear, Nose and Throat Journal 2001; 80(8): 486
3. Evans TC; Hecker J; Zaiser DK. Hemotympanums secondary to spontaneous epistaxis Journal of Emergency Medicine 1988; 6: 387-389
4. Koscove E; Hudson C. Observations on hemotympanum Journal of Emergency Medicine 1989; 7(4): 411-412