**Question:** A 20 year old male comes to casualty with head injury. Examination reveals normal consciousness and blood in the tympanic membrane. Most likely cause is-

A. Subarachnoid haemorrhage
B. Intracranial bleed
C. Middle ear bleed
D. Nasopharyngeal bleed

**Core Concept:**
Head injuries can present with various clinical features, depending on the site and severity of the injury. Blood in the tympanic membrane (tympanic membrane being the eardrum) is indicative of a middle ear bleed.

**Why the Correct Answer is Right:**
In the context of a head injury, blood in the tympanic membrane suggests a traumatic event causing rupture of the tympanic membrane vessels. Among the given options, only middle ear bleed (C) is a plausible cause for this finding.

**Why Each Wrong Option is Incorrect:**
A) Subarachnoid haemorrhage (A) refers to bleeding in the subarachnoid space, which is not associated with blood in the tympanic membrane.
B) Intracranial bleed (B) typically presents with neurological deficits and focal neurological signs, not confirmed by normal consciousness.
D) Nasopharyngeal bleed (D) would present with symptoms and signs related to the nose and pharynx, which is not consistent with the patient's normal consciousness level.

**Clinical Pearl:**
Blood in the tympanic membrane is a clinical sign to consider when evaluating a patient with a head injury. It can be an indicator of a middle ear bleed, which can lead to complications like otorrhoea (ear discharge) and middle ear infection if left untreated.

**Correct Answer:**
C. Middle ear bleed

**Explanation:**
Blood in the tympanic membrane following a head injury can indicate a middle ear bleed. This type of bleed is most commonly caused by trauma to the eardrum or middle ear structures. In such cases, the patient may present with symptoms like otorrhoea and otalgia (earache). Early diagnosis and management are essential to prevent complications like middle ear infection.