Page 1 of 4
(page number not for citation purposes)
Head & Face Medicine
Bilateral spontaneous hemotympanum: Case report
Dimitrios G Balatsouras*1, Panayotis Dimitropoulos1, Alexandros Fassolis1,
Georgios Kloutsos1, Nicolas C Economou1, Stavros Korres2 and
Address: 1Department of Otolaryngology, Tzanion General Hospital, 1 Afentouli & Zanni, Piraeus, Greece and 2Department of Otolaryngology,
Athens National University, Hippokration Hospital, 114 Vas. Sofias Av., Athens, Greece
Email: Dimitrios G Balatsouras* - firstname.lastname@example.org; Panayotis Dimitropoulos - email@example.com;
Alexandros Fassolis - firstname.lastname@example.org; Georgios Kloutsos - email@example.com;
Nicolas C Economou - firstname.lastname@example.org; Stavros Korres - email@example.com; Antonis Kaberos - firstname.lastname@example.org
* Corresponding author
Background: The most common causes of hemotympanum are therapeutic nasal packing,
epistaxis, blood disorders and blunt trauma to the head. Hemotympanum is characterized as
idiopathic, when it is detected in the presence of chronic otitis media. A rare case of spontaneous
bilateral hemotympanum in a patient treated with anticoagulants is presented herein.
Case presentation: A 72-year-old male presented with acute deterioration of hearing. In the
patient's medical history aortic valve replacement 1 year before presentation was reported. Since
then he had been administered regularly coumarinic anticoagulants, with INR levels maintained
between 3.4 and 4.0. Otoscopy revealed the presence of bilateral hemotympanum. The audiogram
showed symmetrical moderately severe mixed hearing loss bilaterally, with the conductive
Tympanograms were flat bilaterally with absent acoustic reflexes. A computerized tomography
scan showed the presence of fluid in the mastoid and middle ear bilaterally. Treatment was
conservative and consisted of a 10-day course of antibiotics, anticongestants and temporary
interruption of the anticoagulant therapy. After 3 weeks, normal tympanic membranes were found
and hearing had returned to previous levels.
Conclusion: Anticoagulant intake should be included in the differential diagnosis of
hemotympanum, because its detection and appropriate treatment may lead to resolution of the
The most common causes of hemotympanum are thera-
peutic nasal packing, epistaxis, blood disorders and blunt
trauma to the head, especially when temporal bone frac-
ture occurs [1,2]. Hemotympanum is characterized as idi-
opathic, when it is detected in the presence of chronic
otitis media [3,4]. In these cases it may be attributed to
chronic middle ear effusions, such as granulation and
cholesterol tissue originating from a cholesterol granu-
Published: 04 October 2006
Head & Face Medicine 2006, 2:31doi:10.1186/1746-160X-2-31
Received: 16 February 2006
Accepted: 04 October 2006
This article is available from: http://www.head-face-med.com/content/2/1/31
© 2006 Balatsouras et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Head & Face Medicine 2006, 2:31http://www.head-face-med.com/content/2/1/31
Page 2 of 4
(page number not for citation purposes)
The aim of this study is to present a rare case of spontane-
ous bilateral hemotympanum in a patient under medica-
tion with anticoagulants.
A 72-year-old male presented in the emergency ward with
acute deterioration of hearing, which occurred during the
past 24 hours. In the patient's past medical history aortic
valve replacement in May 2004, 1 year before presenta-
tion was reported. Since then he had been administered
on a regular basis coumarinic anticoagulants. His INR
(International Normalized Ratio) levels were routinely
checked every month and until presentation INR levels
between 3.4 and 4.0 were maintained. The latest INR
value obtained 2 weeks before the acute deterioration of
hearing was 3.6.
Otolaryngologic clinical evaluation, including micros-
copy of the ear, revealed the presence of bilateral hemo-
tympanum (Fig. 1). The tympanic membrane was intact
but immobile during the Valsalva maneuver. Other find-
ings were unremarkable and clinical examination proved
absence of any other abnormal bleeding on the skin and
mucosae. The patient did not mention any abnormal
bleeding or bruising in the past. Additionally, the patient's
history was clear from chronic middle ear problems or any
underlying systemic disorder associated with defective
hemostasis and from recent activities related with baro-
trauma, such as diving, air travel or Valsalva maneuvers.
Also, he did not report systemic use of salicylates or any
other drugs which could possibly interfere with coagula-
tion, other than the coumarinic anticoagulants. However,
the patient mentioned an overdose of nimesulid 2 days
ago, for an unrelated reason.
An audiogram was obtained, which showed symmetrical
moderately severe mixed hearing loss bilaterally, with the
conductive component predominating. The air-bone gap
for the right ear was 45 dB at 0.25 kHz, 35 dB at 0.5 kHz,
40 dB at 1 kHz, 35 dB at 2 kHz and 25 dB at 4 kHz. The
corresponding values for the left ear were 40 dB, 35 dB, 35
dB, 35 dB and 20 dB. Tympanometry revealed flat tympa-
nograms (type B) bilaterally and absence of acoustic
reflexes both ipsi- and contralaterally. A computerized
tomography (CT) scan was ordered, which showed the
presence of fluid in the mastoid and middle ear bilaterally
Treatment was conservative. A course of antibiotics taken
orally was administered for 10 days, in conjunction with
anticongestants. Additionally, we advised temporary
interruption of the anticoagulant therapy. The patient had
a follow-up otolaryngologic examination after 3 weeks,
during which we found that the tympanic membranes
were mobile and normal in appearance. Audiometric
evaluation showed that hearing had returned to previous
levels and acoustic immittance measures were normal.
After consultation with the patient's cardiologist, cou-
marinic anticoagulants were administered again, but in
lower doses to maintain INR levels between 2.0 and 3.0.
The patient has been followed-up for 6 months at our
clinic, and his state is steady, without any new symptoms
or signs of bleeding.
Hemotympanum may be easily diagnosed by otoscopy,
appearing as partial or total occupancy of the tympanic
membrane by bright red, or purple – dark blue colour.
The bright red colour of the tympanic membrane is
hypothesized to be secondary to oxygen-rich blood owed
to recent hemorrhage, whereas the dark colour may origi-
nate from oxygen-poor blood from a middle ear effusion
or basilar skull fracture . The tympanic cavity derives a
Otoscopic images of bilateral spontaneous hemotympanum, after intake of anticoagulants
Otoscopic images of bilateral spontaneous hemotympanum,
after intake of anticoagulants. Upper: hemotympanum of the
left ear; lower: hemotympamum of the right ear.
Head & Face Medicine 2006, 2:31 http://www.head-face-med.com/content/2/1/31
Page 3 of 4
(page number not for citation purposes)
rich arterial supply from a number of superficial vessels
originating from the external carotid artery , which may
bleed under certain circumstances.
Hemotympanum may be produced by various causes.
Thus, it is important to obtain a detailed medical history
from the patient in order to detect the underlying pathol-
ogy, so that this disorder may be treated properly. The
most commonly reported cause of hemotympanum is
head trauma . A fracture of the temporal bone, usually
resulting from blunt head injury, can produce hemotym-
panum and hearing loss that can be either conductive,
sensorineural or mixed. The conductive element is usually
owed to the presence of blood, which may fill the tym-
panic cavity. Hearing is restored as soon as the blood is
absorbed. However, in cases of persistent hearing loss,
ossicular disruption may be present.
Occasionally, hemotympanum secondary to therapeutic
nasal packing or spontaneous epistaxis was reported [7,8].
Eustachian tube dysfunction is hypothesized to be the
cause of this disorder on both occasions, with peritubal
lymphatic stasis the most probable pathogenetic mecha-
nism . In cases of epistaxis without nasal packing, ret-
rograde reflux of blood through a patulous Eustachian
tube may be implicated .
Several other rare causes of hemotympanum should be
also considered. In advanced tuberculosis blood may pen-
etrate into the middle ear during haemoptysis . Baro-
trauma of the middle ear is another possible cause of
hemotympanum. The most common causes of baro-
trauma today are from the use of the Self-Contained
Underwater Breathing Apparatus (SCUBA), air travel, and
from hyperbaric oxygen chambers. Edmonds from the
CT scan of the mastoid demonstrating bilateral opacity of the tympanic cavity (white arrows)
CT scan of the mastoid demonstrating bilateral opacity of the tympanic cavity (white arrows).
Head & Face Medicine 2006, 2:31 http://www.head-face-med.com/content/2/1/31 Download full-text
Page 4 of 4
(page number not for citation purposes)
Australian Diving Medical Center , devised a grading
system for middle ear barotrauma, based on the otoscopic
appearance of the tympanic membrane. The grading scale
is from Grade 0, when a patient experiences symptoms of
middle ear barotrauma but no physical findings are
present, to Grade V, when a perforation of the tympanic
membrane is apparent. Hemotympanum, evidenced by
blueness and bulging of the tympanic membrane, repre-
sents Grade IV in this scale.
In patients who are on anticoagulants or suffer from leu-
kaemia, spontaneous bleeding within the temporal bone
may also occur . In our patient regular uptake of anti-
coagulants was most probably the cause of spontaneous
bilateral hemotympanum. To our knowledge such a case
has never been reported in the literature so far. Uptake of
nimesulide might be an aggravating factor for the clinical
manifestation of this condition. Antiinflammatory drugs
are known to interfere with blood coagulation. Although
evidence is still inconclusive, it appears that nimesulide
may inhibit platelet aggregation and, additionally, may
inhibit thromboxane A2 formation by platelets at low
concentration . It has been reported that although
nimesulide does not usually affect the response to cou-
marin anticoagulants, a few patients may show some
increase in anticoagulant effect .
In all cases, differential diagnosis between secondary and
idiopathic hemotympanum should be made. The latter is
associated with the presence of cholesterol granuloma
derived from granulomatosus mastoiditis and is charac-
terized by purple colour of the tympanic membrane .
Cholesterol granuloma can be diagnosed by MRI, as it has
a characteristic appearance in T1- and T2- weighed
images. Main et al.  have produced successfully cho-
lesterol granuloma in monkeys under persistent obstruc-
tion of the Eustachian tube.
Treatment of hemotympanum should be, initially, con-
servative. Myringotomy and insertion of a ventilation
tube is indicated for treatment when the condition per-
sists after one month . In these cases, the presence of a
glomus tumor, either involving the jugular bulb (glomus
jugulare) or confined to the middle ear or mastoid
(glomus tympanicum), should be considered . Clini-
cal detection of this disorder is often difficult, and usually,
contrast-enhanced CT scans in conjunction with angiogra-
phy are needed.
In our patient treatment was conservative. Additionally,
we ordered termination of the anticoagulant administra-
tion for a short period of time and prescribed a course of
antibiotics and nasal anticongestants until the absorption
of blood. Resolution was observed after 3 weeks, so that
adjunctive therapeutic measures were not necessary.
Detailed patient's history may lead to accurate diagnosis
of the cause of hemotympanum. We should always search
for rare causes of hemotympanum, such as intake of anti-
coagulants, because appropriate treatment may result in
resolution of the disorder.
The author(s) declare that they have no competing inter-
DGB diagnosed the case and drafted the manuscript. PD
diagnosed the case and assisted in drafting the manu-
script; AF assisted in the diagnostic laboratory work-up of
the patient; GK assisted in the diagnostic laboratory work-
up of the patient; NCE participated in the design and
coordination of the study and assisted in preparing the
manuscript. SK examined the patient and assisted in draft-
ing the manuscript. AK has been involved in revising the
manuscript critically for important intellectual content.
All authors read and approved the final manuscript.
1. Pulec JL, DeGuine C: Hemotympanum from trauma. Ear Nose
Throat J 2001, 80:486.
2. Huff JS, Weimerskirch P: Observations on hemotympanum. J
Emerg Med 1989, 7:411-2.
3. Lalwani AK, Jackler RK: Spontaneous hemotympanum associ-
ated with chronic middle ear effusion. Am J Otol 1991, 12:455-8.
4. Gschwendtner JF, Geurkink NA: The blue eardrum – idiopathic
hemotympanum. Cleve Clin Q 1971, 38:39-42.
5. Gadre AK: Cholesterol granuloma. Ear Nose Throat J 2005,
6.Proctor B: Vasculature of the temporal bone. In Surgical Anat-
omy of the Ear and Temporal Bone 1st edition. Edited by: Proctor B.
New York: Thieme Medical Publishers, Inc; 1989:207-218.
7. Evans TC, Hecker J, Zaiser DK: Hemotympanums secondary to
spontaneous epistaxis. J Emerg Med 1988, 6:387-9.
8. Hurtado TR, Zeger WG: Hemotympanums secondary to spon-
taneous epistaxis in a 7-year-old. J Emerg Med 2004, 26:61-3.
9.McCurdy JA Jr: Effects of nasal packing on eustachian tube
function. Arch Otolaryngol 1977, 103:521-3.
10.Edmonds C: Ear barotrauma. In Diving and Subaquatic Medicine 4th
edition. Edited by: Edmonds C, Lowry C, Pennefather J, Walker R.
London: Arnold; 2002:73-92.
11.Gotay V: Unusual otologic manifestation of chronic lym-
phocytic leukemia. Laryngoscope 1976, 86:1856-63.
12.Saeed SA, Afzal MN, Shah BH: Dual effects of nimesulide, a
COX-2 inhibitor, in human platelets. Life Sci 1998, 63:1835-41.
13.Perucca E: Drug interactions with nimesulide. Drugs 1993,
14.Ìain TS, Shimada T, Lira DJ: Experimental cholesterol granu-
loma. Arch Otolaryngol 1970, 91:356-9.
15.Balatsouras D, Eliopoulos P, Economou C: Multiple glomus
tumors. J Laryngol Otol 1992, 106:538-43.