Understanding Tympanic Membrane Perforation: Causes, Symptoms, and Treatment

Introduction

The tympanic membrane, commonly known as the eardrum, is a circular, semitransparent membrane composed of connective tissue. It separates the external auditory canal from the middle ear and is anchored to the temporal bone via a fibrocartilaginous ring. It functions to receive sound vibrations and convert them into mechanical energy. The malleus (hammer), which is directly attached to the eardrum, transmits these vibrations to the incus and stapes in the middle ear.

Image 1 showing Normal Tympanic membrane

A tympanic membrane perforation is a tear or hole in the eardrum, also known as a ruptured eardrum. It is classified based on its location:

• Central perforation: Most common; occurs at the pars tensa (the main taut portion).

• Marginal perforation: Involves the edges of the membrane.

• Attic perforation: In the upper part (pars flaccida).

• Total perforation: Involves most or all of the eardrum.

Causes of Tympanic Membrane Perforation

1. Trauma

• Direct blow: e.g., a slap over the ear.

• Insertion of objects: Keys, pencils, cotton swabs.

• Loud noises: Explosions, gunshots, or fireworks may generate pressure waves exceeding the eardrum’s tolerance.

• Head injury: May result in perforation, with possible bloody otorrhea or CSF leakage.

2. Infections

• Middle ear infections (otitis media) can lead to pus buildup, increasing pressure until the eardrum ruptures.

3. Barotrauma

• Pressure imbalance during flying, scuba diving, or high-altitude activities can rupture the membrane if the eustachian tube fails to equalize pressure.

4. Iatrogenic Causes

• Accidental damage during ear surgeries or medical procedures.

Symptoms of Tympanic Membrane Perforation

Acute Symptoms

• Severe ear pain, often relieved after rupture due to fluid release.

• Otorrhea: Pus (with infection), blood (trauma), or CSF (skull base injury).

• Tinnitus: Ringing due to impaired hearing mechanisms.

• Vertigo: If the vestibular system is affected.

Chronic Complications

• Hearing loss: Due to impaired sound transmission.

• Chronic otitis media: Ongoing infection due to persistent perforation.

• Cholesteatoma: Accumulation of dead skin forming a benign growth behind the eardrum.

• Mastoiditis: Infection spreading to mastoid air cells.

• Brain abscess or meningitis: From untreated mastoiditis near brain tissues.

Diagnosis

• Direct visualization: With light source; may require pulling the ear.

• Otoscopy: Common and quick in clinical settings.

• Otomicroscopy: More detailed exam by an ENT specialist.

• Tuning fork tests: Identify type and severity of hearing loss (conductive vs. sensorineural).

• Tympanometry: Assesses eardrum mobility.

• Audiometry: Measures hearing across frequencies and volumes.

Treatment Options

1. Spontaneous Healing

• Small perforations often heal within 3–6 weeks.

• Antibiotic ear drops may be prescribed to prevent infection.

2. Surgical Intervention

• Tympanoplasty: Required for large perforations or persistent infections.

Case Presentation

Patient Background

• 43-year-old female with progressive hearing loss for 3–4 years.

• History of chronic otitis media 4 years ago.

Otoscopy Findings

• Complete loss of tympanic membrane.

  
  

  

  Image 2. Otoscopy of patient with complete loss of tympanic membrane.

  
  

Referral for Surgery

• Referred to ENT for tympanoplasty due to complete membrane loss.

Conclusion

Timely recognition and treatment of tympanic membrane perforation are essential to prevent hearing loss and serious complications. Maintaining ear hygiene, avoiding trauma, and seeking prompt medical care for ear issues are critical steps to protect your hearing health.