1. Hemotympanum

2. Definition Presence of extravagated blood within the middle ear
Causes can include:
Post-nasal epistaxis with dysfunction of the Eustachian tubes
Severe head trauma
Coagulopathy
Chronic otitis media
Spontaneous hemotympanum (rare cause)
Vascular lesions (glomus tympanicum, glomus jugulare)

3. Signs and Symptoms Headache Bruising behind ear (Battle’s sign)
Dizziness, vomiting
Hearing loss
Some patients can also be asymptomatic

4. Classification
The presence of fresh blood within the middle ear gives the tympanic membrane a red color. 
The presence of old blood within the middle ear gives the tympanic membrane black or dark purple color. 
Once the hemoglobin degrades with time, the bloody fluid turns to a brownish color and the tympanic membrane is referred to as a chocolate eardrum. 

5. Hemotympanum after head trauma
Otoscopic appearance: Examination of left ear shows clear external auditory canal with an intact tympanic membrane. The middle ear is filled with dark red blood. The drum is stiff and does not move with pneumatic otoscopy. The red arrow denotes the superior orientation. L1

6. Hemotympanum
Otoscopic appearance: Another example of hemotympanum after head trauma. Again a normal canal with intact tympanic membrane. The middle ear is filled with dark red blood. Patient presented with dead ear and vertigo. CT showed disrupted otitc capsule. R1

7. Hemotympanum After Epistaxis
Otoscopic appearance: examination of right ear shows a retracted but intact tympanic membrane. There is a small amount of blood behind the drum anterior to the malleus. Patient has hereditary hemorrhagic telangiectasia and presented with epistaxis. R2

8. Diagnosis Otoscopy evaluation of the tympanic membrane
Audiogram to assess any hearing loss
Indication for imaging:
History of recent head trauma
Suspected middle ear mass (pulsatile mass)
Congenital vascular malformation

9. Treatment Usually conservative (monitoring)
Prophylaxis antibiotics (if worried about infection; rarely indicated)
Myringotomy tube may be necessary for persistent effusion
Spontaneous hemotympanum may need further evaluation to assess underlying etiology.