What is Tympanic Membrane Perforation?
A tympanic membrane perforation is when the tympanic membrane, or eardrum, breaks, leading to a hole between the outer and middle ear. The eardrum is a layer of tissue/cartilage that separates your ear canal from your middle ear and the tiny bones inside it. It helps with hearing by vibrating when it’s hit by sound waves and passing those vibrations on to the inner ear. If the eardrum breaks, it might not vibrate in the same way, which can sometimes cause a person to lose some hearing.
This condition can happen at any age, but it’s often seen in children because it can be a complication of an ear infection. As people get older, injury becomes a more common cause of eardrum rupture. Men are more likely to experience an eardrum perforation compared to women.
The signs and symptoms of an eardrum perforation are the same, no matter what caused the tear. These usually include a sudden pain in the ear that then eases off, along with a discharge from the ear. Ringing in the ear (called tinnitus) and dizziness may also occur.
Generally, an eardrum perforation tends to heal by itself and presents a low risk of complications. However, it’s crucial to know when to seek medical help based on the size and location of the perforation as well as the related symptoms.
What Causes Tympanic Membrane Perforation?
The eardrum, also known as the tympanic membrane (TM), can be damaged or punctured in several ways. This could be due to infections in the ear, such as the common ear infections known as acute otitis media or another caused by a fungus called Aspergillus niger. Injuries can also be a result of pressure changes from activities like scuba diving or flying, or even from things like explosions or sudden changes in pressure. Trauma to the head, loud noises, or inserting objects into the ear can damage the eardrum too. Sometimes, eardrum perforation can happen due to procedures carried out by a healthcare professional while trying to remove a foreign object or earwax from the ear.
With acute otitis media, which is a type of ear infection, the chances of the eardrum rupturing on its own increases with repeated instances of the infection and if the infection is caused by a particular bacteria called non-typeable Hemophilus influenzae.
Most often, eardrum holes are caused by trauma (injury) or this type of ear infection. In rare cases, they have been seen as a result of strikes by lightning. There are also certain risk factors for eardrum rupture, such as having had ear surgeries in the past, severe outer ear infection, and past or present middle ear infections.
Risk Factors and Frequency for Tympanic Membrane Perforation
In simpler terms, it’s not unusual to come across a torn tympanic membrane, also known as a ruptured eardrum, in medical situations. The exact number of these cases isn’t known, because these ruptures often heal on their own. However, a study of almost 1,000 patients in the US highlighted that men are more likely to experience these ruptures due to injury than women, with a ratio of about 1.5 men for every woman. This pattern was also seen in a study conducted in Nigeria on 529 patients, which reported a male to female ratio of 2:1. Yet another study, involving 80 participants, showed that the average age of a patient with a ruptured eardrum is around 26.7, with children representing a fourth of the total sample size.
Signs and Symptoms of Tympanic Membrane Perforation
If a person’s eardrum (known as the tympanic membrane) gets punctured, they may experience symptoms such as sudden ear pain, reduced hearing, bloody ear discharge, and sometimes vertigo (a feeling of being off-balance) or tinnitus (ringing in the ears). This was confirmed by a study from Nigeria that showed the most common symptom was ear discharge (in 81.5% of cases), followed by ear pain (72.8% of cases) and then tinnitus (55.7% of cases). However, vertigo and tinnitus are usually temporary unless the inner ear is also damaged.
Doctors need to check the patient’s ear using an otoscope (a device for examining the inside of the ear) and assess their balance and hearing. This is because the patient’s symptoms might not be caused by their eardrum being perforated but by other neurological issues. Therefore, a detailed neurological examination is also necessary.
Testing for Tympanic Membrane Perforation
A rupture or tear in the eardrum (also known as the tympanic membrane) is a condition that a doctor can usually diagnose by directly examining your ear. But sometimes, the rupture is not immediately visible. In these cases, your doctor might use tools like an otoscope (a device that allows them to see inside your ear) or a tympanometer (a device that tests how well your eardrum moves).
Unfortunately, these tools aren’t always easily available. Furthermore, if a tear is suspected, using an otoscope might not be the best idea, because it could potentially cause more harm to your middle ear. Stated differently, the otoscope could pick up and blow warm, humid air from the back of your throat into your middle ear, through the hole in your eardrum causing further damage.
In some situations, if the otoscope becomes foggy, it could indicate a torn eardrum. This is because the warmth and moisture from the back of your throat can travel to your middle ear through the hole in your eardrum, condensing on the otoscope.
However, to definitively diagnose a hidden or “occult” eardrum rupture, specialized equipment and testing, including microscopic examination of the ear and middle ear pressure studies, are generally needed. These types of tests are usually done at an outpatient clinic, meaning you don’t have to stay overnight in the hospital.
Treatment Options for Tympanic Membrane Perforation
If you have a perforation (or hole) in your eardrum, also called the tympanic membrane (TM), it’s important to remember that these usually heal on their own – and your doctor will primarily aim to help you manage any symptoms in the meantime. It’s crucial to keep your ear as dry as possible, as wetness can increase your risk of infections.
A research study has shown that the use of an ear drop medicine called ofloxacin can help the TM perforation heal faster. However, this medicine didn’t seem to help improve hearing or lessen the chances of getting a particular kind of ear infection caused by large perforations, known as ‘acute otitis media’ (AOM). So, the use of antibiotics is usually not recommended in these cases unless it’s specifically needed.
If the hole in the TM is towards the upper back part of your ear (posterosuperior quadrant), was caused by sudden sharp damaging force (penetrating trauma), or has been persisting for less than two months, it would then need to be treated with surgery. In such cases, you will be referred to a specialist doctor in Ear, Nose, and Throat (ENT) conditions, known as an otolaryngologist.
Moreover, if you’re experiencing any hearing loss due to the TM perforation, you should contact an otolaryngologist and an audiologist (a hearing specialist) early on. They can help diagnose the cause of hearing loss and come up with the best treatment plan for your situation.
What else can Tympanic Membrane Perforation be?
Determining if the eardrum, or tympanic membrane, is ruptured is generally straightforward based on a patient’s symptoms and a physical exam by a doctor. However, the symptoms can also be caused by other medical issues. Physicians may consider these other conditions:
- Otitis media (middle ear infection)
- Otitis externa (external ear infection)
- Traumatic otorrhea (fluid leak due to injury)
- Brain or inner ear tumor
- A stroke affecting the back of the brain
- Ramsay Hunt syndrome (a shingles outbreak affecting the ear)
- Foreign body in the ear
- Blood collection in the ear (auricular hematoma)
- Bullous myringitis (inflammation of the eardrum)
- Labyrinthitis (inner ear inflammation causing dizziness and loss of balance)
- Cholesteatoma (a skin growth in the middle ear)
- Perilymphatic fistula (an abnormal opening in the inner ear)
By asking detailed questions about the patient’s symptoms and performing a complete physical examination, the doctor can narrow down these possibilities to reach a correct diagnosis.
What to expect with Tympanic Membrane Perforation
Generally speaking, the outlook for healing a perforated tympanic membrane (also known as a ruptured eardrum) is excellent. Most of the time, ruptured eardrums heal on their own, which is good news for patients. Studies have shown that small eardrum ruptures usually heal by themselves within three to four weeks. In fact, another study found that 90% of ruptured eardrums closed up on their own over a six-week period.
However, there are a couple of things that might interfere with this healing process. For example, if the rupture is large or if the patient gets an infection, these factors could slow down the healing or even prevent the eardrum from closing up at all. In these cases, or for people who have chronic (long-term) eardrum ruptures or other complications, doctors might recommend surgery.
After surgery, a patient’s eardrum might re-rupture anywhere from 7% to 27% of the time. Research has shown that the most important factor affecting the success of the surgery is the skill of the surgeon.
Because of the potential for delayed complications, doctors will typically want to monitor patients for many years after surgical intervention. The main health impact of a ruptured eardrum is associated hearing loss, which can benefit from repair treatment. However, it’s important to know that, overall, the rates of serious health problems and death linked to ruptured eardrums are low.
Possible Complications When Diagnosed with Tympanic Membrane Perforation
When someone’s eardrum (TM) is punctured, they could develop a persistent ear infection known as chronic otitis media. This infection may potentially period it can progress towards affecting the tiny bones in the inner ear (ossicles), which plays a significant role in hearing. Over time, this could result in long-term sensorineural hearing loss. In a study involving 529 patients, the most common complication identified was hearing loss; this impacted more than half of the patients (52.6%). However, the majority of these cases involved only mild to moderate hearing loss.
If the infection becomes chronic, there’s a risk that it could lead to facial nerve paralysis by affecting the seventh cranial nerve (CN VII) located in the middle ear. The infection can also spread to the brain, potentially leading to severe conditions such as meningitis or a brain abscess.
Prolonged ear infection due to a perforated eardrum might lead to mastoiditis, an infection in the mastoid bone behind the ear. Cholesteatomas, abnormal skin growths in the middle ear, can also form over time, devastating the middle ear bones and even eroding into the inner ear. This, in turn, could result in permanent hearing loss and bouts of dizziness (vertigo).
Most patients with these complications would need surgery and should promptly consult with an ear, nose, and throat specialist (otolaryngologist).
- Persistent ear infection (chronic otitis media)
- Possible progression to affect inner ear bones, impacting hearing
- Long-term sensorineural hearing loss
- Facial nerve paralysis due to infection affecting the seventh cranial nerve (CN VII) in the middle ear
- Severe conditions through infection spread to the brain such as meningitis or a brain abscess
- Mastoiditis, an infection in the mastoid bone behind the ear due to prolonged ear infection
- Cholesteatomas, abnormal skin growths in the middle ear
- Permanent hearing loss and bouts of dizziness (vertigo) due to cholesteatomas
- The necessity of surgery for most patients with these complications
- Recommendation for prompt consultation with an ear, nose, and throat specialist (otolaryngologist)
Preventing Tympanic Membrane Perforation
The tearing or puncturing of the tympanic membrane, which is the thin layer that separates your ear canal from your middle ear, often happens accidentally. Because of this, it’s challenging to prevent. However, there’s one thing patients can control: they should stop using cotton swabs to clean their ears. A cotton swab can lead to direct injury or even poke a hole in this layer.
In one study, 949 patients with ruptured tympanic membranes were observed. Of these, 261 cases were caused by using cotton swabs to clean their ears. To prevent this damage, it’s critical to avoid cotton swabs.
If a person has a ruptured tympanic membrane, it’s crucial to keep the ear dry. This is because if water gets in the ear, it can lead to a condition called AOM (Acute Otitis Media). AOM, deep inflammation of the middle ear, could result in further complications.
