Tympanic membrane perforation, a common finding, is typically caused by infection, trauma, or iatrogenic effects. The clinical presentation varies according to the size and location of the perforation. Symptomatic individuals will have a conductive hearing loss and possibly other signs as well. Diagnosis is based on otoscopy and further testing.
Tympanic membrane perforation is a rare medical entity. There are numerous causes, of which infection, trauma, and iatrogenic consequences are the most frequent [1] [2]. Of importance, perforation results as a complication from acute and chronic otitis media [3] [4]. Moreover, one particular study found a link between recurrent acute otitis media and spontaneous perforation [5]. Iatrogenic effects stem from procedures such as ear irrigation, outcomes related to tympanostomy tubes [6] [7], or even cerumen removal. Other etiologies of perforation include blunt trauma to the ear and exposure to elevated atmospheric pressure such as with explosions, diving, and air travel [8] [9]. Specifically, tympanic membrane perforation is the most prevalent finding with ear trauma [10].
One of the main features is conductive hearing loss [11], which correlates with the size of the perforation [12]. In addition to the latter, the effects are reflective of the location of the perforation and the presence of any other existing condition. If associated with otitis media or cholesteatoma, the perforation is typically painful. Additionally, a concomitant ear infection with perforation may be associated with copious purulent drainage.
Individuals with perforation may hear whistling sounds during pressure changes situations such as sneezing or nose blowing. Additionally, affected individuals are vulnerable to infection when water enters the ear canal and during upper respiratory illness. The perforation may last for a short duration or persist. If it does not spontaneously heal, it becomes chronic with residual perforation.
A perforated tympanic membrane is identified during routine otoscopy although smaller sized ones may need otomicroscopy. If pneumatic otoscopy is done, it reveals an immobile tympanic membrane in affected patients [13].
Note that the tympanic membrane may be obscured by cerumen, foreign objects, or outgrowths of skin or cartilage that are present in the external auditory canal [14]. Additional challenges in visualizing the tympanic membrane can occur due to difficulty with proper positioning; the latter is especially seen in children.
Once a perforation is diagnosed, audiometry is performed but is usually normal. This should be repeated prior to and after any surgical procedure.
Impedance testing may be advised as well. Tympanometry in affected individuals is associated with a flat type B tympanogram, which is a finding consistent with perforation [13]. This requires specialized tools.
If the perforation is not confirmed with the above tests, another technique can be done. This involves filling the patient's affected ear canal with saline or distilled water followed by execution of the Valsalva maneuver. Consequently, the presence of stream bubbles renders this a positive result.
Imaging is only obtained if there is evidence of bone destruction or cholesteatoma. Otherwise, X-rays and magnetic resonance imaging (MRI) are not usually performed.