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Tympanic Membrane Perforation

TMP

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.


Presentation

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.

Military Personnel
  • On February 25, 1990, an Iraqi SCUD missile exploded inside a building housing United States military personnel in Dhahran, Kingdom of Saudi Arabia.[ncbi.nlm.nih.gov]
Otalgia
  • These patients had been referred to us for evaluation of chronic, mostly treatment-refractory otitis externa, which had manifested as otorrhea, otalgia, and/or pruritus.[ncbi.nlm.nih.gov]
  • Large sizes of 25% and more were found to occur in humid and wet seasons, and also, clinical presentations of otorrhea (65.6%), otalgia (51.5%), tinnitus (37.1%), and ear itching (34.4%) seemed to worsen.[ncbi.nlm.nih.gov]
  • The most common presenting symptom among the patients was otorrhea in 81.5%, otalgia in 72.8%, and tinnitus in 55.7%.[ncbi.nlm.nih.gov]
  • Clinical manifestations  Otalgia  Bleeding  Fullness  Hearing loss: conductive HL or mixed HL  Tinnitus  Shape of perforation is split 5.[slideshare.net]
Ear Discharge
  • MAIN OUTCOME MEASURES: Healing outcome at 4, 8, 12 weeks; effects of perforation size, location, and mode of injury, active intervention and ear discharge on healing outcome.[ncbi.nlm.nih.gov]
  • You may also have ear discharge, tinnitus (ringing or buzzing sound in the ear), or dizziness. Ear discharge may be clear, bloody, or yellowish and thick. A mild eardrum perforation may heal on its own over time.[drugs.com]
  • Unilateral/bilateral CSOM of safe type with no history of ear discharge for atleast 6 weeks were selected randomly irrespective of age and gender.[indianjotol.org]
  • In contrast, if patients get recurrent ear discharge or their hearing is persistently poorer than before the injury, they should seek a referral to the ENT clinic.[entsho.com]
Suggestibility
  • The average age was much higher than that of patients with other types of cholesteatoma, suggesting that it must require long periods of time to establish the disease.[ncbi.nlm.nih.gov]
  • Our results suggest that the silk fibroin patch technique is a suitable treatment for chronic tympanic membrane perforation. 2b Laryngoscope, 126:2798-2803, 2016.[ncbi.nlm.nih.gov]
  • These findings suggest that CM modified with CBD-bFGF could be therapeutically appropriate for the treatment of TM perforation.[ncbi.nlm.nih.gov]
  • The observation that all those who died in hospital and most of those who were unstable were not examined by the ENT services suggests that impact of TMP as an indicator of severity may be underestimated.[ncbi.nlm.nih.gov]
  • […] significantly more and less common, respectively, among children without a history of TMP than among those who suffered from this complication (OR 2.17, 95% CI 1.09-4.41, P 0.02, and OR 0.42, 95% CI 0.21-0.84, P 0.01).This study is the first report suggesting[ncbi.nlm.nih.gov]

Workup

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.

Treatment

  • The treatment was repeated up to 4 times for cases in which complete closure of the TMP was not achieved after 1 round of treatment.[ncbi.nlm.nih.gov]
  • These patients were treated with the following prominent methods of treatment: gelatin sponge patch treatment and edge approximation plus gelfoam patching. Measurement indicators were perforation closure rate and mean closure time at 3 months.[ncbi.nlm.nih.gov]
  • Treatments were an ESM patch or a perforation edge approximation. We divided patients into two groups according to the treatment used. Each patient was matched by treatment onset and perforation size.[ncbi.nlm.nih.gov]
  • A randomized prospective analysis was performed between February 2009 and January 2011 for the treatment of traumatic TMP larger than 50% of the entire tympanic membrane.[ncbi.nlm.nih.gov]
  • These patients had been referred to us for evaluation of chronic, mostly treatment-refractory otitis externa, which had manifested as otorrhea, otalgia, and/or pruritus.[ncbi.nlm.nih.gov]

Prognosis

  • This study aimed to retrospectively evaluate the prognosis and outcome of tympanic membrane perforations with a particular focus on the fate of the perforation edge flaps.Chart records of 329 patients with a single ear traumatic tympanic membrane perforation[ncbi.nlm.nih.gov]
  • The authors report that tinnitus, vertigo and hearing loss (secondary to traumatic TM perforation) often have a good prognosis, despite various and multiple therapeutic protocols and a lack of consensus as to how to "best" treat traumatic TM perforation[audiology.org]
  • Lou ZC, Hu YX, Tang YM (2011) Prognosis and outcome of the tympanic membrane flap at traumatic tympanic membrane perforation edge. ORL J Otorhinolaryngol Relat Spec 73: 212-218.[omicsonline.org]

Etiology

  • Genetics Genetic susceptibility has been reported for recurrent acute otitis media (AOM) and chronic otitis media with effusion (COME), two of the etiologies of perforations ( 1 ).[unboundmedicine.com]
  • This study aimed at determining the clinicoepidemiological pattern, etiological factors, clinical presentation, and management of tympanic membrane perforation in a tertiary hospital in Nigeria.[ncbi.nlm.nih.gov]
  • Code First Code First Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • Etiology  Direct force  Careless while removal wax by himself or herself  Skull fracture may tear TM  Hot slag fly into the ear  Indirect force  Increase in violence and firearms  Barotrauma 3.[slideshare.net]

Epidemiology

  • Epidemiology Incidence in the general population is unknown because many perforations heal spontaneously.[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • Risk Factors Eustachian tube dysfunction and inability to equalize middle ear pressures Rapid changes in ambient pressures (air flight or diving) Insertion of objects into ears Head trauma, exposure to explosions Etiology and Pathophysiology Barotrauma[unboundmedicine.com]
  • Pathophysiology The eardrum tends to heal itself. Even eardrums that have been perforated multiple times often remain intact.[oralmaxillo-facialsurgery.blogspot.com]

Prevention

  • The knowledge of variations of the tympanic membrane (TM) perforations with the climatic changes in the West African subregion would help clinicians in its prevention and management.[ncbi.nlm.nih.gov]
  • Preventions  Be caution while removing your wax  Using ear plug 9. The End[slideshare.net]
  • A mastoidectomy may also help prevent your eardrum from breaking down. Tympanoplasty: This surgery repairs your torn eardrum and any damage to your inner ear. A tympanoplasty also helps prevent ear infections that stop and come back.[drugs.com]

References

Article

  1. Isaacson B. Hearing loss. Med Clin North Am 2010;94(5):973–988.
  2. Luetje CM. Reconstruction of the tympanic membrane and ossicular chain. In: Bailey B, Johnson J, Newlands S, eds. Head & neck surgery otolaryngology. 4th ed. Philadelphia, PA: Lippincott: Williams & Wilkins; 2006.
  3. Kerschner JE. Otitis media. In: Kliegman RM, Stanton BF, St Geme JW, Schor NF, Behrman RM, eds. Nelson textbook of pediatrics. 19th ed. Philadelphia, PA: Saunders; 2011:2199–2213.
  4. Casselbrant ML, Mandel EM. Acute otitis media and otitis media with effusion. In: Kliegman RM, Stanton BF, St Geme JW, Schor NF, Behrman RM, eds. Nelson textbook of pediatrics. 19th ed. Philadelphia, PA: Saunders; 2011:2761–2777.
  5. Marchisio P, Esposito S, Picca M, et al. Prospective evaluation of the aetiology of acute otitis media with spontaneous tympanic membrane perforation. Clin Microbiol Infect. 2017: pii: S1198-743X(17)30019-8.
  6. Daudia A, Yelavich S, Dawes PJ. Long-term middle-ear ventilation with subannular tubes. J Laryngol Otol. 2010;124(9):945–949.
  7. Zimmerman WD, Ganzel TM, Windmill IM, et al. Peripheral hearing loss following head trauma in children. Laryngoscope. 1993;103(1 Pt 1):87-91.
  8. Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol. 2005;119(5):366–70.
  9. Lou ZC, Lou ZH, Zhang QP. Traumatic tympanic membrane perforations: a study of etiology and factors affecting outcome. Am J Otolaryngol. 2012;33(5):549–555.
  10. Conoyer JM. Otologic surgery following ear trauma. Otolaryngol Head Neck Surg. 2007;137(5):757–761.
  11. Park H, Hong SN, Kim HS, et al. Determinants of Conductive Hearing Loss in Tympanic Membrane Perforation. Clin Exp Otorhinolaryngol. 2015;8(2):92-96.
  12. Mehta RP, Rosowski JJ, Voss SE, O'Neil E, Merchant SN. Determinants of hearing loss in perforations of the tympanic membrane. Otol Neurotol. 2006;27(2):136–143.
  13. Gunasekera H, O'Connor TE, Vijayasekaran S, et al. Primary care management of otitis media among Australian children. Med J Aust. 2009;191(9 Suppl): S55–S59.
  14. Naylor JF. Otoscope fogging: examination finding for perforated tympanic membrane. BMJ Case Reports. 2014;2014:bcr2013200707.

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Last updated: 2018-06-21 19:45