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.

• Pleural Effusion

  Complementary tests: echocardio-gram was normal; chest CT scans showed minor left pleural effusion and two fractured costal arches. Lab tests revealed CPK-MB of 2540 IU and normal troponin levels. Audiometry tests were not available at admission. [bjorl.org]

• 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]

  However, the majority of the patients that I see with acute traumatic tympanic membrane perforations are symptomatic, and their prime complaints are decreased hearing, tinnitus, and otalgia. [jamanetwork.com]

  The subject lost his consciousness temporarily at the time of the accident and was sent to an Intensive Care Unit complaining of dyspnea, intense chest pain, and bilateral otalgia and tinnitus. [bjorl.org]

• 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]

  Otomicroscopic view of central perforation of tympanic membrane in a patient presenting with ear discharge and hearing loss (click on image for an enlarged view) Central perforation of tympanic membrane is that which is not involving the annulus and is [pgblazer.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]

• Hearing Impairment

  Conductive hearing impairment accounted for 61.6% while sensorineural hearing impairment 25.3%. The most common degrees of hearing impairment were mild and moderate and accounted for 47.1% and 25.1%, respectively. [ncbi.nlm.nih.gov]

  In this study, conductive hearing impairment is the most common type of hearing impairment and accounted for 326 (61.6%) followed by sensorineural hearing impairment in 134 (25.3%) and mixed hearing impairment in 69 (13.1%). [njcponline.com]

  Knowledge of the degree of hearing impairment is critical and a complete hearing assessment will be obtained. [entforkidsalabama.com]

  Correlation of hearing impairment with site of tympanic membrane perforation. Journal Institute Med. 2005;27(2):. Ibekwe TS, Nwaorgu OG, Ijaduola TG. Correlating the site of tympanic membrane perforation with Hearing loss. [ijorl.com]

• Otorrhagia

  Physical examination: cyanosis of the face, upper third of the chest, and anterior and posterior portion of the chest (Figure 1A); bilateral otorrhagia and epistaxis, and subconjunctival hemorrhage (Figure 1B). [bjorl.org]

• Erythematous Tympanic Membrane

  Normal Tympanic Membrane Pink Tympanic Membrane, often seen with fever or upper respiratory tract infections Bulging and erythematous Tympanic Membrane in AOM Otitis Media with Effusion "glue ear" Middle ear effusion Loss of TM landmarks, particularly [rch.org.au]

• Responsiveness Decreasing

  OBJECTIVES: VEMP responses decrease with impairment of sound transmission, such as in conductive hearing loss (CHL). COM with tympanic membrane (TM) perforation is a common disorder that causes various degrees of CHL. [ncbi.nlm.nih.gov]

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.

• Pleural Effusion

  Complementary tests: echocardio-gram was normal; chest CT scans showed minor left pleural effusion and two fractured costal arches. Lab tests revealed CPK-MB of 2540 IU and normal troponin levels. Audiometry tests were not available at admission. [bjorl.org]

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]

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. [esciencecentral.org]

Genetics Genetic susceptibility has been reported for recurrent acute otitis media (AOM) and chronic otitis media with effusion (COME), two etiologies that may lead to the complication of TM perforation (1)[C]. [unboundmedicine.com]

Common etiologies include acute or chronic infection, eustachian tube dysfunction, trauma, and previous ear surgery (including PE tube placement). [tricare.mil]

After obtaining a history in terms of perforation etiology and duration from occurrence to patient presentation, all patients underwent ENT and general examinations. [medcraveonline.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]

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

Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics. 2017;140(3). Epub 2017/08/09. pmid:28784702 conflicts of interest to disclose. [journals.plos.org]

Epidemiology of otitis media in a local tropical African population. West Afr J Med 2005;24:227-30. 25. Sarojamma DSR, Raj S, Satish HS. A clinical study of traumatic perforation of tympanic membrane. IOSR J Dent Med Sci 2014;13:24-8. 26. [phmj.org]

Eustachian tube dysfunction and inability to equalize middle ear pressures Rapid changes in ambient pressures (air flight or deep-water diving) Insertion of objects into ears, frequent cotton tip use Head trauma, exposure to explosions Etiology and Pathophysiology [unboundmedicine.com]

Pathophysiology The eardrum tends to heal itself. Even eardrums that have been perforated multiple times often remain intact. [oralmaxillo-facialsurgery.blogspot.com]

CONTEXT: 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]

People should avoid inserting any objects into their ear, even to clean the ear, to prevent damage to the eardrum. [medicalnewstoday.com]

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.