Tympanic membrane perforation

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Overview

Tympanic membrane perforation is when the tympanic membrane (TM) ruptures, creating a hole between the external and middle ear. The TM is a layer of cartilaginous connective tissue, with skin on the outer surface and mucosa covering the inner surface that separates the external auditory canal from the middle ear and ossicles. The TM function is to aid in hearing by creating vibrations whenever struck by sound waves and transmitting those vibrations to the inner ear.[1] When the tympanic membrane perforates, it may no longer create the vibrational patterns, leading to hearing loss in some instances. 

Tympanic membrane rupture can occur at any age, although it is mainly seen in the younger population, associated with acute otitis media. As a patient's age increases, trauma becomes a more likely cause of TM rupture. Men are more likely to experience TM perforation compared to women. 

Signs and symptoms of tympanic membrane perforation are the same despite the cause of the rupture. There is often sudden onset of pain, followed by relief, with associated otorrhea. Tinnitus and vertiginous symptoms may also be experienced. 

Overall, TM perforation has a favorable prognosis with a small risk of complications. Perforations tend to heal spontaneously without intervention. It is important to know when intervention and early referral is required, based on size, location, and symptoms associated with the perforation.

Symptoms

Ear pain that may subside quickly.

Mucuslike, pus-filled or bloody drainage from the ear.

Hearing loss.

Ringing in the ear (tinnitus)

Spinning sensation (vertigo)

Nausea or vomiting that can result from vertigo.

Causes

Causes of a ruptured (perforated) eardrum may include:

Middle ear infection (otitis media). A middle ear infection often results in the accumulation of fluids in the middle ear. Pressure from these fluids can cause the eardrum to rupture.

Barotrauma. Barotrauma is stress exerted on the eardrum when the air pressure in the middle ear and the air pressure in the environment are out of balance. If the pressure is severe, the eardrum can rupture. Barotrauma is most often caused by air pressure changes associated with air travel.

Other events that can cause sudden changes in pressure — and possibly a ruptured eardrum — include scuba diving and a direct blow to the ear, such as the impact of an automobile air bag.

Loud sounds or blasts (acoustic trauma). A loud sound or blast, as from an explosion or gunshot — essentially an overpowering sound wave — can rarely cause a tear in the eardrum.

Foreign objects in your ear. Small objects, such as a cotton swab or hairpin, can puncture or tear the eardrum.

Severe head trauma. Severe injury, such as a skull base fracture, may cause the dislocation of or damage to middle and inner ear structures, including the eardrum.

Risk factors

Having an ear infection.

History of eardrum ruptures, or ear surgery, such as ear tubes.

Scuba diving.

Injury to the ear.

Inserting objects in the ear.

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Complications

The eardrum (tympanic membrane) has two primary roles:

Hearing. When sound waves strike it, the eardrum vibrates — the first step by which structures of the middle and inner ears translate sound waves into nerve impulses.

Protection. The eardrum also acts as a barrier, protecting the middle ear from water, bacteria and other foreign substances.

If the eardrum ruptures, uncommon problems can occur, especially if it fails to self-heal after three to six months. Possible complications include:

Hearing loss. Usually, hearing loss is temporary, lasting only until the tear or hole in the eardrum has healed. The size and location of the tear can affect the degree of hearing loss.

Middle ear infection (otitis media). A ruptured (perforated) eardrum can allow bacteria to enter the ear. If a perforated eardrum doesn't heal, a small number of people may be vulnerable to ongoing (recurrent or chronic) infections. In this small group, chronic drainage and hearing loss can occur.

Middle ear cyst (cholesteatoma). Although very rare, this cyst, which is composed of skin cells and other debris, can develop in the middle ear as a long-term result of eardrum rupture.

Ear canal debris normally travels to the outer ear with the help of ear-protecting earwax. If the eardrum is ruptured, the skin debris can pass into the middle ear and form a cyst.

A cyst in the middle ear provides a friendly environment for bacteria and contains proteins that can damage the bones of the middle ear.

Prevention

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.

Avoid swimming until your ear heals.

If you get an ear infection, get it treated right away.

Try to avoid flying in airplanes when you have a cold or sinus infection.

Use earplugs, chew gum, or force a yawn to keep your ear pressure stabilized.

Don’t use foreign objects to clean out extra earwax (showering every day is usually enough to keep your earwax levels balanced).

Wear earplugs when you know that you’ll be exposed to a lot of noise, such as around loud machines or at concerts and construction sites.