Myringitis Granulosa: Understanding a Rare Middle Ear Disorder

What Is Myringitis?

The term myringitis means inflammation of the tympanic membrane (TM) of the ear, mostly involving the lateral surface with or without the involvement of the external auditory canal.

Myringitis can be of two types: acute or chronic.

• Acute myringitis consists of bullous myringitis (BM), also known as bullous hemorrhagic myringitis (infection leading to painful blisters in the ear), and fungal myringitis (fungal infection of the middle ear).

• Chronic myringitis includes chronic inflammation of the ear, which consists of myringitis granulosa or granular myringitis (presence of granulation tissue on the tympanic membrane) and eczematoid myringitis (chronic infection of the tympanic membrane). These conditions vary in etiology and treatment. However, their symptoms may resemble.

The acute infection after three weeks turns to subacute, and within three months, it turns to chronic. As the tympanic membrane is the first component of the middle ear, it is the first to traumatize and affect the patient's work and life.

What Is Granular Myringitis?

Granular myringitis is a rare condition that is characterized by the presence of granulation tissue (tissue forms due to chronic inflammation) on the outer surface of the tympanic membrane with or without the involvement of a deep bony external auditory canal (a passage that leads from the opening of the external ear to the tympanic membrane or ear drum). The granulations can be either localized (at one place) or diffuse (at multiple locations). This granulation tissue keeps on growing slowly for years without proper treatment.

What Is the Difference Between Granular Myringitis and Bullous Myringitis?

Granular myringitis is a type of chronic myringitis, and bullous is the acute form of myringitis.

Granular Myringitis (Chronic Myringitis)

• Pathology - Chronic inflammation.

• Etiology - Trauma (external cause).

• Microorganisms Involved - Staphylococcus aureus and Pseudomonas aeruginosa.

• Symptoms - Painless otorrhea (drainage of liquid from ear).

• Appearance of Lesion - Granular or ulcerative.

• Type of Hearing loss - Normal or conductive.

• Complications - Symptoms tend to recur.

• Treatment - Surgery is a better option than topical ear drops.

Bullous Myringitis (Acute Myringitis)

• Pathology - Acute inflammation.

• Etiology - Otitis media, inflammation or infection in the middle ear (Internal cause).

• Microorganisms Involved - Streptococcus pneumoniae and Hemophilus influenzae.

• Symptoms - Severe pain, maybe otorrhea.

• Appearance of Lesion - Blister or cystic.

• Type of Hearing loss - Conductive hearing loss (sound is not reaching the inner ear due to obstruction).

• Complications - Hearing loss may persist.

• Treatment - Analgesics, decongestants, and antibiotics can be used to relieve the symptoms.

What Are the Symptoms of Granular Myringitis?

The symptoms of granular myringitis include -

• Foul-smelling discharge from the ear.

• A sensation of fullness in the ear.

• Irritation.

• Mild pain or itching in the ear.

What Is the Cause of Myringitis Granulosa?

Determining the cause of inflammation of the tympanic membrane is essential to treat the condition. Many conditions can lead to inflammation of the tympanic membrane, including -

• Staphylococcus pyogenes and aureus.

• Escherichia coli and Klebsiella species.

• Streptococcus aureus and Streptococcus epidermidis.

• Hemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis (can be found in 70 percent of cases).

Other causes include -

• Fungal and viral infections such as herpes zoster and influenza.

• Eczematous otitis externa, which can cause eczematous myringitis.

• Granulation tissue covering the tympanic membrane.

• Extra-esophageal reflux.

How Is Myringitis Granulosa Diagnosed?

Some of the following tests can be done to diagnose -

Before performing any test, the external auditory canal is gently cleaned, and irrigation of the ear canal is done to remove any excess debris. However, this may be contraindicated in cases where the status of the tympanic membrane is unknown.

• Tympanocentesis - A tiny puncture is made in the tympanic membrane or eardrum to permit entry into the middle ear canal. This will help collect the sample for culture and identify the offending causative agent.

• Pneumatic Otoscopy - This test provides information on the appearance and mobility of the tympanic membrane.

• Pure Tone and Speech Audiometry - This test consists of an oscillator or signal generator, an attenuator (the electronic device that stabilizes the power of the signal), and an amplifier (the electronic device that increases the strength of the electronic signal). This test helps identify the nature and cause of hearing loss in a patient.

• Myringotomy - In case of acute infections, this procedure is done to relieve the pressure in the ear and drain the fluid buildup in the ear.

Other than that, some of the following imaging tests can also be done to check the condition of the tympanic membrane such as -

• High-resolution computed tomography (CT) scan of the temporal bones (present at the side of the face).

• Magnetic resonance imaging (MRI) for detecting intracranial complications due to any ear infection.

What Are the Complications Related to Granulosa Myringitis?

The complications related to myringitis include -

• Chronic suppurative otitis (chronic infection of the middle ear).

• Inflammation or infection in the ear (otitis media).

• Hearing loss.

• Tympanic membrane perforation.

• Facial paralysis.

• Vertigo or dizziness.

What Is the Treatment for Myringitis?

The condition of myringitis can be quite painful; therefore, medicines such as analgesics, anti-inflammatory medications, antipruritics, and antihistamines may be prescribed to help relieve the symptoms. If a patient suspects ear infection, fluid drainage, or foreign bodies in the ear, they should seek immediate medical assistance. In case of suppurative complications or perforated tympanic membrane, the patient should consult an ENT (ear-nose-throat) specialist.

In the case of tympanic membrane perforation, specific treatment has to be done, including -

• Solution of alcohol-containing salicylic acid that can be used in the middle ear region, which helps stimulate the growth of the epithelium. However, in some cases, the alcohol can cause ear pain and irritation, and the application of this solution should be stopped immediately.

• The aqueous solution can also be used to help eliminate inflammation in the middle ear region.

Surgery is the other option to treat the perforation in the tympanic membrane, and the method used for this is called myringoplasty. In this method, the perforation or hole in the eardrum is repaired by using a film or paper. The epidermis and mucosa continue to grow on the film, which helps fill up the perforation completely.

In case of localized infection of granular myringitis, meticulous microscopic debridement can be done, which helps in cleaning the ear canal by using a microscope. In the diffuse form of infection, topical chemical cautery with silver nitrate or laser evaporation of granulation tissue can also be done.

Conclusion:

Granular myringitis is a chronic inflammation of the tympanic membrane with the occurrence of granulation tissue. This is a rare condition, but the symptoms followed by this condition can be very annoying and painful. Therefore, patients should be aware of the symptoms and should consult a specialist in case of experiencing any of the symptoms.