Bleeding from the ear, known as otorrhagia, is an alarming symptom that requires medical investigation. The ear is divided into the outer, middle, and inner sections. The inner ear contains the cochlea, vestibule, and semicircular canals, which are responsible for hearing and balance. While visible blood usually signals injury to the outer or middle ear, any bleeding may indicate a serious problem involving deeper structures. True inner ear hemorrhage, which is bleeding directly into the fluid-filled labyrinth, is a medical emergency demanding immediate attention to preserve function.
Clarifying the Source of Ear Bleeding
When blood appears in the ear canal, the source is usually the external auditory canal or the tympanic membrane. Bleeding from the outer ear canal results from minor trauma, such as a scratch from a cotton swab, an abrasion from a foreign object, or an infection like otitis externa. A doctor should examine the ear to ensure the damage is superficial.
Bleeding originating from the middle ear often indicates a perforated eardrum. This can occur from severe pressure changes, a loud noise, or a middle ear infection. When infection causes fluid pressure to build up, the eardrum may rupture, releasing a discharge that contains blood. Although a ruptured eardrum often heals on its own, it requires medical management to prevent infection.
True inner ear hemorrhage is rarely visible externally unless the blood passes through a torn eardrum or if a severe head injury has occurred. Following trauma, blood may collect in the middle ear space behind the eardrum, a condition known as hemotympanum. This pooling of blood signifies injury that has affected the vascular supply near the inner ear structures.
Serious Medical Conditions That Cause Inner Ear Hemorrhage
The most serious cause of bleeding affecting the inner ear is a temporal bone fracture resulting from significant head trauma. The temporal bone encases the inner and middle ear apparatus. A fracture line extending into this area can lacerate blood vessels, leading to hemorrhage into the inner ear labyrinth. Transverse fractures, which run perpendicular to the temporal bone, are associated with damage to inner ear structures and severe hearing loss.
Sudden, extreme pressure changes, known as barotrauma, can also cause labyrinthine hemorrhage. This frequently occurs during activities like scuba diving or flying when the pressure differential is too great for the ear to equalize. This causes small vessels within the inner ear to rupture, resulting in a sudden loss of inner ear function.
Rarer causes include certain vascular and systemic conditions. Abnormal blood vessel formations, such as arteriovenous malformations or aneurysms near the ear, can rupture and cause bleeding. Patients taking anticoagulant medications or those with blood disorders like leukemia are also at an elevated risk of severe bleeding due to impaired clotting.
Associated Symptoms and Immediate Medical Response
Damage to the inner ear is almost always accompanied by distinct neurological and auditory symptoms. The hallmark signs of inner ear injury include profound, sudden sensorineural hearing loss and severe vertigo, an intense spinning sensation. Tinnitus, or persistent ringing in the ear, is also a common complaint suggesting damage to the cochlea or its associated nerves.
A highly concerning symptom is clear or watery fluid mixing with the blood draining from the ear, which may indicate a cerebrospinal fluid (CSF) leak. This leak suggests a severe skull base fracture has torn the protective membranes around the brain, allowing fluid to escape. Facial weakness or paralysis is another red flag, indicating damage to the facial nerve running through the temporal bone.
If ear bleeding follows head trauma or is accompanied by dizziness, vomiting, or profound hearing changes, seek emergency medical care immediately. Avoid putting cotton, swabs, or liquid into the ear, as this can introduce infection or stop the drainage of important fluid. Allow any fluid or blood to drain freely while waiting for emergency services.
Diagnostic Procedures and Treatment Protocols
Diagnosis begins with a physical examination and a high-resolution computed tomography (CT) scan. The CT scan is the preferred initial imaging to rapidly identify temporal bone fractures or blood pooling in the middle ear (hemotympanum). A complete audiology test is necessary to determine the extent and type of hearing loss, which helps localize the injury.
Magnetic Resonance Imaging (MRI) is often used to visualize soft tissue damage and confirm labyrinthine hemorrhage. Specialized MRI sequences can detect the abnormal signal intensity caused by blood products within the inner ear’s fluid-filled chambers. If a vascular cause is suspected, a CT angiogram (CTA) may be performed to assess the integrity of major blood vessels near the skull base.
Treatment depends on the underlying cause and severity. For stable patients with hemorrhage following barotrauma, treatment is often conservative, involving bed rest, head elevation, and close observation to allow the blood to reabsorb. If a severe fracture or a CSF leak is confirmed, surgical intervention may be required to repair the skull base defect or manage a vascular injury. The prognosis for recovery is variable and depends on the extent of the initial damage to the sensory structures.