The Etiology and Clinical Course of Bullous Myringitis

DAVID O. MERIFIELD, MD, AND GEORGE S. MILLER, MD, TULSA, OKLA

BULLOUS myringitis is a common condition characterized by vesicular eruptions of the tympanic membrane. In the majority of cases the condition is self-limited, although serious complications have been reported.1-3 The disease is primarily one of childhood, but is frequently seen in adults. Bullous myringitis is generally thought to be of viral origin, although several investigations have failed to establish this.2,4,5 Recent studies suggest a relationship to influenza virus6 and the Eaton agent,7-9 a pleuro-

pneumonia-like organism (Mycoplasma pneumoniae) known to be capable of producing primary atypical pneumonia. It is the
purpose of this report to consider these and other possible causative agents in a prospective study of 23 cases of bullous

myringitis.

Historical Review
A detailed review of the subject can be found in a previous publication.3 In brief, the symptom complex was apparently first recognized during the pandemics at the turn of the century.10 Otologists of the day were so impressed with the frequent occurrence of bullous lesions of the tympanic membrane in influenza that these changes were felt to be pathognomonic of "la grippe."
Submitted for publication April 7, 1966. From the Oklahoma University College of Medicine, Tulsa (Dr. Merifield) and the University of Colorado, Denver (Dr. Miller). Reprint requests to 370 Doctors Bldg, Tulsa, Okla 74103 (Dr. Merifield).

Since that time the disease has been vari ously ascribed to streptococcal otitis,11 latent scurvy,12 and viruses.2"3 Jenkins 4 first sug gested that "filter passers" might be responsi ble, but was unable to relate the disease to the herpes virus. Senturia and Sulkin 5 failed to isolate an infectious agent from aspirated bullous fluid, and in six cases complementfixation studies were negative for influenza viruses. Yoshie,6 however, was able to isolate influenza virus from the middle ear of four out of ten patients during a Japanese in fluenza epidemic. A surprisingly high incidence of hemor rhagic myringitis (without middle-ear ef fusion) was reported by Rifkind et al 8 in susceptible volunteers infected with the Eaton agent (13 out of 25). In two cases the myringitis progressed to serous-filled blebs which later filled with blood (one was aspi rated and cultured without success). Sobeslavsky et al8 reported the isolation and identification of the Eaton agent in three naturally infected children with otitis media, one of whom presented with serous bullous myringitis. These reports strongly suggest that influenza viruses and the Eaton agent play causative roles in bullous myringitis.

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Materials and Methods study population represented 23 consecutive cases diagnosed as bullous myringitis. Each patient was examined by at least two physicians. Ten cases developed a frank hemorrhagic appearance to the blebs, while the remaining 13 contained clear or yellowish fluid. Acute and postconvalescent sera
The

weeks) were obtained in all cases and testing for complement-fixing anti body against Mycoplasma pneumoniae. In addition, ten pairs of the serum were tested for the presence of complement-fixing antibody against parainfluenza I, parainfluenza II, parainfluenza III, in fluenza A, influenza B, influenza C, adenovirus, respiratory syncytial virus, psittacosis, mumps, polio II, polio III, Echo 9, Echo 16, rubeola, coxsackie A9, coxsackie Bl, coxsackie B2, coxsackie B3, coxsackie B6, and herpes simplex. Throat swabs were cultured by the method of
(five
to ten

submitted for

Chanock " for Eaton agent, and also for bacteria by routine methods. Since the presence of cold agglutinins and Streptococcus MG agglutinins also represent fairly reliable evidence of infection from the Eaton agent, these studies were also performed in each case. Values for the white blood cell counts and chest x-ray films were normal.

superficial incision of the vesicles for relief pain; however, there is no unanimity as to the effectiveness of this procedure. Be cause of the possible introduction of bac terial organisms, even superficial incision must be carefully considered. Following rupture of one or more bullae, a serosanguineous discharge appears in the meatus which is generally of short duration unless complicated by bacterial invasion when the discharge becomes purulent. Sig nificant or persistent temperature elevation is not part of the uncomplicated course of the
of
onset

disease and should alert the physician to the of suppurative otitis, associated re

Results
Isolation recovery procedures and comple ment-fixation tests failed to establish any re lationship between the Eaton agent and the cases of bullous myringitis observed. In no case was a rise in cold agglutinin or Strepto coccus MG antibody titer found. No signifi cant or constant change in antibody titer in complement-fixation tests against the viral agents listed above could be demonstrated. One chest x-ray film was reported as "proba ble right suprahilar and left basilar infiltrate," but the remainder of these exami nations were within normal limits. Throat cultures for bacteria grew normal flora in all but one case. Blood counts were unremark able except in three instances where 4%, 15%, and 25% atypical lymphocytes were

keeping with views previously pre sented,8 treatment consisted only of frequent observation unless evidence of bacterial superinfection was found. All cases except three cleared spontaneously in less than two weeks. In two of the three cases resolution occurred after three weeks. One patient, however, required bilateral myringotomy and adenotonsillectomy because of persistent mucoid otitis media.
In

spiratory disease,

or

encephalitis.

Comment Results of this study fail to confirm previ suggestive evidence that the Eaton agent or influenza virus bear a direct causal rela tionship to bullous myringitis. Despite the rather broad spectrum of infectious agents studied, no significant rise in antibody titer was demonstrated. This is especially sur prising since a history of recent or current upper-respiratory infection was obtained in every instance. If viruses or pleuropneumonia-like organisms can produce bullous lesions by direct involvement of the tym panic membrane, the specific agents re sponsible apparently were not included in this investigation. This thesis could certainly be held as plausible, since a multitude of other agents are capable of producing upperrespiratory symptoms and many of these infectious agents probably are yet to be identified. If the Eaton agent and those viruses which were tested for are capable of
ous

reported.

Clinical Course and Treatment

Classically, the blebs are said most often to appear on the posterior aspect of the drum and meatal wall. The bullae, true vesicles be neath the epithelial stratum, present them selves as sharply demarcated blebs. The patient's complaint of pain is usually out of proportion to local and constitutional findings. Adjectives such as "stinging,"

"agonizing," "violent," and "excruciating" bear witness to the striking character of the

discomfort associated with the disease. Severe otalgia may persist 24 to 72 hours or longer, but is usually about five hours in duration. Various authors recommended the

producing bullous myringitis, they parently were not involved in this series
therefore
are

ap

and at least not the sole offenders.

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It is conceivable that the bullous lesions may be nonspecific. That is, they may re sult from any one of a variety of insults. Perhaps they are simply manifestations of a mechanical injury which follows upper-re spiratory infection of any sort (eg, eustachian tube insufficiency, fever, etc). Evidence to support this thesis can be in ferred from the fact that 11 of the 23 cases were associated with collection of mucoid material or serous fluid. We consider this a surprising finding since the classical descrip tions of bullous myringitis do not allow the frequent presence of middle-ear effusion. One can easily justify the use of anti biotics, vasoconstrictors, etc; however, their value has yet to be established in what ap pears to most commonly be a self-limited

disease. It should be emphasized, however, that careful follow-up is most important since serious complications, while infre quent, do occur.1"3

Summary
were

agents listed above. These studies, in ad

throat cold, and MG ag glutination tests, failed to establish a causal relationship. Therapy and the clinical course of the disease are briefly discussed. dition to viral isolation cultures for Eaton agent,

Twenty-three cases of bullous myringitis investigated as to possible etiology by complement-fixation tests against the Eaton agent and ten cases against 21 common viral techniques,

Drs. Robert . Chanock and Gilles R. G. Monif aided in this study. Mr. Horace Turner of the National Institutes of Health performed the serological examinations.

REFERENCES
1. Karelitz, S.: Myringitis Bullosa Haemorrhagica, Amer J Dis Child 53:510-615 (Feb) 1937. 2. Dawes, J.: Myringitis Bullosa Haemorrhagica: Its Relationship to Otogenic Encephalitis and Cranial Nerve Paralysis, J Laryng 67:313-342 8. Rifkind, D., et al: Ear Involvement (Myringitis) and Primary Atypical Pneumonia Following Inoculating of Volunteers With Eaton Agent, Amer Rev Resp Dis 85:479-489 (April) 1962. 9. Sobeslavsky, O., et al: The Etiological Role of Mycoplasma Pneumoniae in Otitis Media in Children, Pediatrics 35:653-657 (April) 1965. 10. Loewenberg, B.: Influenza-Otitis in 1891,

(June) 1953. 3. Merifield, D.: Hemorrhage Bullous Myringitis: Its Relation to Perceptive Deafness, Ann Otol 71: 124-134 (March) 1962. 4. Jenkins, G.: Proceedings Royal Society of Medicine, J Laryng 41:527 (Aug) 1926. 5. Senturia, B., and Sulkin, S.: The Etiology of Myringitis Bullosa Haemorrhagic, Ann Otol 51:476\x=req-\ 482 (June) 1942. 6. Yoshie, C.: On Isolation of Influenza Virus From Middle Ear Discharge of Influenza Otitis Media, Jap J Med Sci Biol 8:373-377 (Oct) 1955. 7. Chanock, R.M., et al: Respiratory Disease in Volunteers Infected With Eaton Agent: A Preliminary Report, Proc Nat Acad Sci USA 47:887\x=req-\
890, 1961.

Trans Amer Otol Soc 5:70-83, 1891. 11. Boies, L.: Fundamentals of Otolaryngology, Philadelphia: W. B. Saunders Co., 1959. 12. Ruskin, S.L.: Contribution to the Study of Grippe Otitis: Myringitis Bullosa Haemorrhagica and Its Relationship to Latent Scurvy, Laryngoscope 48:327-334 (June) 1938. 13. Chanock, R.M., et al: Growth on Artificial Medium of an Agent Associated With Atypical Pneumonia and Its Identification as a PPLO, Proc Nat Acad Sci USA 48:41, 1962.

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