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.

• Pain

  You can take steps at home to treat ear pain. Put warm compresses on the ear to help relieve discomfort. Use medicines such as ibuprofen or acetaminophen to ease pain. [medlineplus.gov]

  Pain medication was used for a mean duration of 2.0 days, with the mean pain scale score determined to be 0.1 on the third postoperative day. [24] Inlay versus underlay surgery A study by Haksever et al found that inlay butterfly transcanal cartilage [emedicine.medscape.com]

  Other symptoms may include sharp ear pain or a sudden decrease in ear pain; bloody, clear or pus-like drainage; noise or buzzing in the ear; hearing loss; and other symptoms. [nationalsinusinstitute.com]

  A ruptured or perforated eardrum usually causes pain if the cause is infectious (ear infection) or traumatic; however, other causes may not cause pain. [medicinenet.com]

• Surgical Procedure

  Many types of perforation heal on their own, but it is always important to visit your ENT doctor in Arlington, Dallas or Fort Worth to make sure you do not need a surgical procedure. [centralparkent.net]

  5 Additional materials, namely vein or fascia, soon followed the use of canal skin in the evolution of this surgical procedure.6,7 The cases reported in this paper are restricted to those persons having complete loss of the tympanic membrane before grafting [jamanetwork.com]

  Tympanic membrane perforations are usually caused by trauma, infection, surgical procedures such as tympanoplasty or myringoplasty. [dbpia.co.kr]

  In this surgical procedure, a new eardrum is harvested from the patient's own body tissue (temporalis fascia or tragal perichondrium). [fauquierent.net]

• Severe Pain

  Traumatic perforation of the TM causes sudden severe pain sometimes followed by bleeding from the ear, hearing loss, and tinnitus. [smartypance.com]

  Symptoms and Signs of Traumatic TM Perforation Traumatic perforation of the tympanic membrane causes sudden severe pain sometimes followed by bleeding from the ear, hearing loss, and tinnitus. [msdmanuals.com]

  If pressure change or poking something in your ear caused the perforation, you will have: Sudden severe pain Sometimes a little bleeding You may not have any complications or symptoms after an eardrum perforation. [merckmanuals.com]

• Chronic Infection

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

  Therefore a hole in this membrane increases the risk of infections as well as to cause degrees of hearing loss. A picture of a normal tympanic membrane. A perforation can be the result of trauma, or of acute and chronic infections. [sydneyentclinic.com]

  Perforations that result from infections, as when a tympanic membrane bursts, or when chronic infections have led to irreparable damage to the membrane itself, often do not heal. Figure 2. [ent.weill.cornell.edu]

  In other cases, chronic infection and drainage associated with a perforation or larger perforations will not heal on their own and may require surgical repair. [masseyeandear.org]

• Pruritus

  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]

  Otic topical drops often contain a corticosteroid to minimize pruritus, inflammation, and edema but are not necessary for successful treatment. A wide range of otic and ophthalmic drops may be used successfully. [entokey.com]

• Dermatitis

  Flying and Ear Problems Cell phone Use May Cause Ear Pain/Dermatitis Ear plugs to protect the ears from water: Any information provided on this website should not be considered medical advice or a substitute for a consultation with a physician. [fauquierent.net]

• Fracture

  Sometimes when the tympanic membrane is perforated, the small bones of the inner ear, called ossicles, are fractured at the same time. A ruptured eardrum may cause hearing loss in the affected ear, but this is usually temporary. [vernickandgopal.com]

  Physical examination  Tympanic perforation  Central perforation  Marginal perforation  Blood crust  If skull base fracture is occurred with CSF leakage, clear fluid is observed. 6. [slideshare.net]

  There are three different types of orbital fractures: orbital rim fractures, blowout fractures and direct orbital floor fractures. [sinaigrace.org]

  Red flags Significant generalised head- or polytrauma – use the ATLS approach Battle's sign – ecchymosis (bruising) behind the ear can be a sign of skull base fracture Facial nerve palsy When to involve the ENT registrar Immediately: Temporal bone fracture [entsho.com]

  Traumatic causes of tympanic membrane perforation include Insertion of objects into the ear canal purposely (eg, cotton swabs) or accidentally Concussion caused by an explosion or open-handed slap across the ear Head trauma (with or without basilar fracture [msdmanuals.com]

• Tinnitus

  In our study regardless of mechanism of injury, tinnitus was the most common complaint (90.90%). [indianjotol.org]

  In these cases, you may experience a dramatic loss of hearing and tinnitus. Causes The causes of a perforation or tear in the eardrum are usually due to injury, infection, or chronic Eustachian tube disorders. [centralparkent.net]

  In this report, a 43-year-old male patient with unilateral tympanic membrane perforation, tinnitus, and bilateral sensorineural hearing loss caused by thunderbolt strike is presented through a review of the literature. [ncbi.nlm.nih.gov]

  Median size of perforations was 33.0%; Patients main complaints were blockage of the ears/ hearing loss and tinnitus. [ajol.info]

  Symptoms can include conductive hearing loss, aural fullness, pain, tinnitus, and exudate. Some patients with TM perforations may by asymptomatic. In many cases, the TM perforation heals on its own. [medtronic.com]

• 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]

  Clinical manifestations  Otalgia  Bleeding  Fullness  Hearing loss: conductive HL or mixed HL  Tinnitus  Shape of perforation is split 5. [slideshare.net]

  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

  It was significantly delayed by large perforations estimated at 50% or more of entire tympanic membrane, ear discharge, wrong intervention on acute perforation by ear syringing, and by penetrating injuries sustained through the ear canal (P < 0.05, P [ncbi.nlm.nih.gov]

  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]

  […] reduce the surface tension of the water and makes it more likely to pass through the perforation and into the middle ear) Advise the patient to attend their GP/local walk-in centre for ear drops if they develop ear discharge and pain Further management [entsho.com]

  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]

• 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]

  Correlation of hearing impairment with site of tympanic membrane perforation. Journal of Institute of Medicine, 27 (2), 2-5. Retrieved from https://www.nepjol.info/index.php/JIOM/article/view/394 [nepjol.info]

  Determinants of Hearing Loss in Perforations of the Tympanic Membrane. Otol Neurotol. 2006;27(2):136-43. Bhusal CL, Guragian RPS, Shrivastav RP. Correlation of hearing impairment with site of tympanic membrane perforation. [ijorl.com]

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

• Suggestibility

  Persistent conductive hearing loss suggests disruption of the ossicular chain, necessitating surgical exploration and repair. Many perforations are small and heal spontaneously. [msdmanuals.com]

  RESULTS: 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]

• Vertigo

  Perilymphatic fistula – Radiates to the affected ear and may be associated with severe hearing loss, vertigo, clear otorrhea. [visualdx.com]

  Manifestations Ear pain during descent that stops suddenly Clear or bloody drainage from ear Hearing loss Ringing in the ear (tinnitus) Spinning sensation (vertigo) Nausea or vomiting that can result from vertigo Management Most perforated eardrums will [diversalertnetwork.org]

  Patients with marked hearing loss or severe vertigo are evaluated by an otolaryngologist as soon as possible. Exploration may be needed to assess and repair damage. [msdmanuals.com]

  […] from vertigo When to see a doctor Call your doctor if you experience any of the signs or symptoms of a ruptured eardrum or pain or discomfort in your ears. [mayoclinic.org]

• Confusion

  If possible, audiometric studies are done before and after treatment to avoid confusion between trauma-induced and treatment-induced hearing loss. [msdmanuals.com]

  Not to be confused with the secondary tympanic membrane of the round window Eardrum Right eardrum as seen through a speculum. [en.wikipedia.org]

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.

Office treatments The first option is to perform one of the available office treatments. Such treatments have the best chance of working when the perforation is small and involves neither the umbo nor the annulus. Several methods apply. [emedicine.medscape.com]

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]

A ruptured eardrum usually heals within a few weeks without treatment. Sometimes, however, a ruptured eardrum requires a procedure or surgical repair to heal. [mayoclinic.org]

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]

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]

Etiology In our study, the most common etiology of traumatic perforation of TM was injury caused due to physical assault (69.42%). [indianjotol.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]

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

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]

Preventions  Be caution while removing your wax  Using ear plug 9. The End [slideshare.net]

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

Seek prompt evaluation from your primary care doctor to prevent potential damage to the eardrum. Protect your ears during flight. If possible, don't fly if you have a cold or an active allergy that causes nasal or ear congestion. [mayoclinic.org]

There are multiple things that you can do to prevent future eardrum ruptures. Prevention tips Keep your ear dry to prevent further infection. Gently stuff your ears with cotton when you bathe to prevent water from entering the ear canal. [healthline.com]

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