Idiopathic or spontaneous hemotympanum (SH) is an uncommon disorder characterized by a black-blue tympanic membrane discoloration as a result of recurrent hemorrhage in the middle ear or mastoid in the presence of eustachian tube obstruction. Initial evaluation of a blue middle ear mass includes an audiogram and computed tomography (CT) scan with intravenous contrast. CT may identify congenital vascular malformation or bone erosion due to chronic otitis media or tumors. A magnetic resonance imaging (MRI) scan is useful in distinguishing hemotympanum from a vascular tumor and avoiding angiography, which is associated with significant morbidity. Evidence suggests that secretory otitis media and SH are different phases of the same disease process.