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Perforated Tympanic Membrane
Timothy R. Takagi, MD
image BASICS
  • The tympanic membrane (TM), or “ear drum” is a thin, trilaminar barrier that separates the external auditory canal (EAC) from the middle ear. Along with the ossicles of the middle ear, it transmits and amplifies sound vibrations to the cochlea.
  • The TM consists of an outer squamous layer, contiguous with the EAC skin, the middle fibrous layer of both peripheral annular fibers and central radial fibers that provide support, and the inner mucosal layer, contiguous with the middle ear lining.
  • Rupture of the TM can disrupt hearing and can allow pathogens access to the middle ear space from the EAC.
  • Perforations may be classified by location:
    • Central: doesn't involve the annulus and is more likely to heal, spontaneously
    • Marginal: lies in the periphery, involves the annulus; may be associated with cholesteatoma; is less likely to heal and harder to repair
    • Involvement of the malleus decreases chance of healing.
    • Perforations of the posterior superior quadrant overly the ossicles and the cochlea and are associated with more extensive damage.
    • When a TM perforation heals, the mucosal and squamous layers reepithelialize, but the fibrous layer won't, resulting in a thinner membrane (paradoxically termed “monomeric”)
  • Classification of perforations by etiology:
    • Infectious: acute/chronic suppurative otitis media
    • Traumatic: barotrauma, (e.g., diving), acoustic trauma, (e.g., explosion), self-inflicted/penetrating (cotton tips)
    • Middle ear mass: cholesteatoma or neoplasm
    • Iatrogenic: persistent perforation after myringotomy tube placement or secondary acquired cholesteatoma
  • The TM possesses the ability for spontaneous closure resulting in formation of a dimeric membrane (outer squamous and inner mucosal). However, if this does not occur, a persistent perforation will result.
Incidence in the general population is unknown because many perforations heal spontaneously.
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).
Preservation of eustachian tube function, avoiding insertion of foreign bodies and objects into the EAC, and prompt treatment of significant infection and inflammation of the ear, reduces the chances of perforation.
  • 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
  • Barotrauma: Sudden of large changes in the pressure differential across the TM (such as in air flight or diving underwater)
  • Direct penetration of the TM by a foreign object (e.g., cotton swab)
  • Otitis media: Purulent, inflammatory process leads to ischemia and necrosis of the TM
  • Inflammation and erosion results from neoplasm, cholesteatoma, and localized infection (e.g., otomycosis).
  • Chronic eustachian tube (craniofacial abnormalities, such as cleft may predispose)
  • OME
  • Recurrent AOM
  • Cholesteatoma
  • Tympanosclerosis
  • Ossicular chain damage (if traumatic perforation)
  • Otoscopic exam: Pay attention to location and size of any TM defect, as well as involvement of the annulus or the malleus. Also, inspect ear canal to look for evidence of otomycosis.
  • Pneumatic otoscopy will reveal no motion because air passes freely into the middle ear space, and may induce vertigo (positive “fistula” sign).
  • Fogging of the otoscope, in what otherwise appears to be a dry ear, may reveal occult perforation (2)[C].
  • Note foreign bodies (cotton swabs, PE tubes). Batteries are a particular concern, due to the risk of acid leakage.
  • Retraction pocket (chronic eustachian tube dysfunction and possible resulting cholesteatoma) typically in the posterosuperior quadrant
  • Thinned TM segment indicates past, healed perforation.
  • Keratin debris consistent with cholesteatoma (pearly white +/− chronic drainage)
  • Mass in the middle ear space behind the TM (cholesteatoma, paragangliomas, CN VII schwannomas, etc.)
  • An ulceration of the EAC, contiguous with the TM annulus, should lead to suspicion of squamous cell carcinoma.
  • If history of hearing loss on that side: Weber (512-kHz tuning fork to center of forehead; if conductive hearing loss, sound should lateralize to the perforated side) and Rinne tests (place tuning fork to mastoid; when vibration no longer heard, transfer tuning fork next to outside ear canal; air conduction should be greater than bone conduction)
  • Facial nerve palsy is uncommon to have with an isolated TM perforation. This is likely due to more occult pathology.
  • Inspection of oropharynx for tonsillar asymmetry or neoplasm, that can cause eustachian tube obstruction.
  • Hemotympanum
  • Audiogram can reveal normal hearing or a mild conductive hearing loss:
    • A simple perforation will typically result in a low-frequency conductive hearing loss.
    • An audiogram that demonstrates a worse-than-expected conductive hearing loss or sensorineural hearing loss is more suspicious for ossicular chain damage or middle ear pathology.
  • Tympanometry demonstrates an increased volume in the ear and decreased pressure (can demonstrate perforation even if not present on otoscopic exam); acoustic immittance demonstrates a volume >2 mL.
  • MRI and CT imaging are not indicated for routine TM perforations.
  • If there is suspicion for cholesteatoma or CN VII palsy, then obtain noncontrast CT of the temporal bone as initial imaging study.
  • Tympanosclerosis may be confused with early cholesteatoma.
  • Prior perforation (thin, healed membrane may be hard to discern)
  • Cholesteatoma without perforation may still demonstrate chronic drainage.
  • Most TM perforations are nonurgent and do not require immediate evaluation by an otolaryngologist. Often, these can be managed with drops and pain control to decrease inflammation; ENT follow-up in few days to a week
  • A significant portion of TM perforations heal spontaneously without additional intervention due to the TM's regenerative capacity.
  • Observation of >3 months is a feasible option in select patients with uncomplicated, small perforations.
  • Debate exists over dry ear precautions. But conservatively, patients should avoid getting water into the EAC and into middle ear space. Typical showering is less of an issue, but swimming in rivers/swimming pools should be avoided until the perforation has healed.
  • P.783

  • Treatment of purulence with topical antibiotic drops will reduce otorrhea.
  • If significant bleeding, topical Afrin can also be instilled in the ear canal.
  • Most perforations are associated with minimal hearing loss (<40 dB) and lack vestibular complaints.
  • Perforations with hearing loss >40 dB, any degree of ipsilateral facial weakness, those associated with vestibular symptoms, or those associated with cholesteatoma require referral to ENT; for traumatic perforation, obtain evaluation within 48 hours.
  • For some patients with chronic eustachian tube dysfunction, having a perforated TM is a favorable situation because it allows for the equalization of pressure in the middle ear that would otherwise be more difficult because of the decreased eustachian tube function, thus obviating the need for tympanostomy tube placement later. For these patients, dry ear precautions are recommended.
  • Topical antibiotic and combined antibiotic/anti-inflammatory drops are the mainstay of treatment for AOM with perforation. These can be used for 5 to 7 days. Topical antibiotic drops should be continued if persistent otorrhea; may need evaluation by an otolaryngologist if drainage does not resolve with ototopical medication.
  • Some topical antibiotics (gentamicin, neomycin sulfate, or tobramycin) may rarely cause ototoxicity with TM perforations because they absorb through the round window into the inner ear.
  • While nonototoxic drops are preferred, cost and availability may be relevant considerations given the rarity of oto- and vestibulotoxicity (3)[C].
  • Oral antibiotics are not recommended for AOM with perforations because antibiotic drops are more effective. Oral antibiotics should be used in AOM prior to perforation.
  • Oral antibiotics are not indicated for the isolated TM perforation.
First Line
  • Ciprofloxacin ear drops ± dexamethasone
  • Ofloxacin ear drops
  • Dry ear precautions (cotton ball with petroleum jelly while showering and use of hairdryer to dry out ear if water enters the EAC)
  • Dry ear precautions should be used if patients will be swimming in lakes/rivers, to minimize the introduction of pathogens into the EAC/middle ear cavity.
  • Prevent infection primarily with eardrops or oral antibiotics as a secondary measure.
  • For patients who participate in water sports as a part of daily life, such as swimmers and divers, repair is recommended to provide the patient a “safe ear.”
  • A case-by-case risk-benefit analysis must be performed in cases of conductive hearing loss because surgery entails the risk of hearing loss.
  • Myringoplasty can be performed if the perforation is small and appears to be favorable. This is often performed with gel, paper patch, or other material (silk), which provides a scaffold across which the TM can heal.
  • Tympanoplasty is performed for larger perforations, persistent perforations, or anteriorly based perforations. Perichondrium, fat, cartilage, pericranium, and temporalis fascia are often used in reconstructing the TM.
  • A combined tympanoplasty/mastoidectomy surgery might be required for large perforations, chronic draining ears, presence of cholesteatoma, damage to the ossicular chain, or with evidence of mastoid disease.
  • Surgery is often an outpatient procedure and may be done under sedation and local anesthesia. General anesthesia can also be used.
  • Patients can receive mastoid compressive dressings and instructions for postoperative antibiotics.
  • Potential major complications of surgery include worsening of hearing, facial nerve damage, CSF leak, bleeding, and repair failure.
  • Ossiculoplasty might also be performed if pathology involves the ossicular chain; full repair of the ossicular chain can be performed as a primary procedure or as a second look.
    • If ossicular chain discontinuity is repaired, patients will require postoperative audiogram to evaluate airbone gap.
The presence of comorbid disease like mastoiditis or meningitis would require inpatient stabilization with IV antibiotics/imaging and appropriate care for those disorders.
Patient Monitoring
  • Follow-up should be done to confirm TM healing and to obtain an audiogram.
  • It is vital to reexamine the ear, especially after an episode of infection associated with a perforation, to rule out underlying cholesteatoma or chronic eustachian tube dysfunction, which may be contributing to the perforation.
No dietary restrictions
  • Dry ear precautions
  • Avoid cotton swabs in the ear.
  • Call physician for worsening hearing loss, vertigo, facial nerve palsy, fever, or persistent drainage.
  • Most perforations will heal spontaneously; however, large perforations and those associated with a chronic draining ear often require surgery.
  • Mortality associated with this condition is low, but there is a potential for infection to spread to the mastoid, leading to meningitis, if proper aural care is not maintained.
1. Rye MS, Blackwell JM, Jamieson SE. Genetic susceptibility to otitis media in childhood. Laryngoscope. 2012;122(3):665-675.
2. Naylor JF. Otoscope fogging: examination finding for perforated tympanic membrane. BMJ Case Rep. 2014;2014. doi: 10.1136/bcr-2013-200707.
3. Haynes DS, Rutka J, Hawke M, et al. Ototoxicity of ototopical drops—an update. Otolaryngol Clin North Am. 2007;40(3):669-683, xi.
Additional Reading
  • Jensen RG, Koch A, Homøe P. Long-term tympanic membrane pathology dynamics and spontaneous healing in chronic suppurative otitis media. Pediatr Infect Dis J. 2012;31(2):139-144.
  • 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.
  • Morris PS, Leach AJ. Acute and chronic otitis media. Pediatr Clin North Am. 2009;56(6):1383-1399.
  • H72.90 Unsp perforation of tympanic membrane, unspecified ear
  • H72.00 Central perforation of tympanic membrane, unspecified ear
  • H72.2X9 Other marginal perforations of tympanic membrane, unsp ear
Clinical Pearls
  • To evaluate a patient with a suspected TM perforation, history and physical exam will usually suffice and does not require imaging.
  • Nonhealing perforations associated with malodorous or recurrent infections are often associated with cholesteatoma and an otolaryngology consultation is recommended.
  • Retraction pockets and history of AOM are suspicious for chronic eustachian tube dysfunction.
  • Tympanoplasty surgery might be required for a perforation that does not spontaneously heal.
  • Sudden sensorineural hearing loss warrants urgent referral and initiation of steroid therapy the same day.
  • Sudden facial paralysis warrants urgent referral and initiation of steroid therapy ± antiviral treatment.