Tympanic membrane perforation
A full-thickness defect in the eardrum from trauma or infection, causing sudden ear pain, conductive hearing loss, and otorrhea. Diagnosis is by otoscopy. Most heal spontaneously with dry-ear precautions; a draining ear is treated with ofloxacin otic drops, and a perforation that fails to close by 3 months is referred for myringoplasty or tympanoplasty.
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What this article covers
- Overview
A tympanic membrane perforation is a full-thickness hole in the eardrum separating the ear canal from the middle ear.
- Epidemiology
Tympanic membrane perforation occurs across all ages but clusters in two groups: young children, in whom it most often follows acute otitis media, and older children through adults, in whom trauma…
- Risk factors
Acute otitis media: the most common infectious antecedent, particularly with recurrent or delayed-treatment episodes.
- Pathophysiology
The membrane has three layers: outer squamous epithelium continuous with canal skin, a middle fibrous layer giving tensile strength, and an inner mucosal layer continuous with the middle ear.
- Clinical features
Sudden otalgia: sharp pain at the moment of rupture, easing abruptly once middle ear pressure releases.
- Differential diagnosis
Acute otitis media without perforation: a bulging, erythematous, hypomobile membrane with loss of the light reflex, but the membrane remains intact.
- Diagnosis
Diagnostic standard: established by otoscopy that directly visualizes a full-thickness defect; pneumatic otoscopy confirms it by showing absent membrane mobility at the edge.
- Management
First-line for an uncomplicated, non-draining perforation: dry-ear precautions (a water-tight earplug while showering, no swimming, no forceful nose-blowing), then re-examine at 4 to 6 weeks to document closure.
- Complications
Chronic suppurative otitis media: persistent or recurrent otorrhea through a perforation that fails to close for more than 6 weeks.
- Prognosis
Most perforations, whether from acute otitis media or uncomplicated trauma, heal spontaneously; about 90% close within 6 to 8 weeks with dry-ear precautions, and hearing returns to baseline once the membrane is intact.
- Prevention
Prompt treatment of acute otitis media: limits pressure necrosis and spontaneous rupture.
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Related articles
- Acute otitis media
Acute otitis media is a suppurative middle ear infection, mostly in young children, diagnosed by otoscopy showing a bulging, erythematous tympanic membrane with an effusion, and it is treated with observation or amoxicillin depending on age and severity.
- Chronic suppurative otitis media
Chronic suppurative otitis media is continuous otorrhea through a perforated tympanic membrane for more than six weeks without systemic symptoms. Management starts with topical fluoroquinolone ear drops and aural toilet, escalating to systemic antibiotics or tympanoplasty for refractory disease or cholesteatoma.
- Cholesteatoma
Cholesteatoma is an abnormal growth of keratinizing squamous epithelium in the middle ear that erodes the ossicles, mastoid, and adjacent skull base; it is confirmed on otoscopy, staged by CT, and requires mastoidectomy with tympanoplasty because no medical therapy is curative.
- Mastoiditis
Acute mastoiditis is a suppurative infection of the mastoid air cells, almost always arising as an extension of untreated or inadequately treated acute otitis media. It is diagnosed clinically by postauricular erythema, tenderness, and swelling with the auricle displaced anteriorly, and is treated with intravenous antibiotics escalating to myringotomy or mastoidectomy when abscess or complications are present.
- Middle ear barotrauma
Middle ear barotrauma is injury to the tympanic membrane and middle ear from a pressure gradient the eustachian tube cannot equalize, typically during aircraft descent or diving. Most cases are mild and resolve with decongestion and pressure avoidance, but severe cases progress to hemotympanum or tympanic membrane rupture.
- Hearing loss
Hearing loss is evaluated with the Weber and Rinne tuning fork tests to sort conductive from sensorineural loss at the bedside, then confirmed with audiometry; treatment ranges from cerumen removal or hearing aids to urgent oral prednisone and otolaryngology referral for sudden sensorineural loss.