TYMPANIC MEMBRANE PERFORATION – Signs and Symptoms, Diagnostic Evaluation and Management
The eardrum serves two important functions in the ear. It senses vibrating sound waves and converts the vibration into nerve impulses that convey the sound to brain. It also protects the middle ear from bacteria as well as water and foreign objects. Normally, the middle ear is sterile. But when the eardrum is ruptured, bacteria can get into the middle ear and cause an infection known as otitis media.
A ruptured eardrum is a tear in the thin membrane that separates outer ear from inner ear and when there is any abnormal opening or perforation in tympanic membrane, it is termed as perforated tympanic membrane.
ETIOLOGY
Traumatic causes of TM perforation include:
- A number of things can cause the eardrum to rupture; one of the most common causes is an ear infection. When the middle ear is infected, pressure builds up and pushes against the eardrum. When the pressure gets too high, it can cause the eardrum to perforate.
- Insertion of objects into the ear canal purposely: another common cause of a ruptured eardrum is poking the eardrum with a foreign object, such as a cotton-tipped swab or a bobby pin that is being used to clean wax out of the ear canal. Sometimes children can puncture their own eardrum by putting objects, such as a stick or a small toy in their ears.
- Concussion caused by an explosion or open-handed slap across the ear
- Head trauma
- Sudden negative pressure (e.g. strong suction applied to the ear canal)
- Barotraumas: this happens when the pressure inside the ear and the pressure outside the ear are not equal. That can happen, for example, when an aeroplane changes altitude, causing the air pressure in the cabin to drop or rise. The change in pressure is also a common problem for scuba divers.
- Iatrogenic perforation during irrigation or foreign body removal
SIGNS AND SYMPTOMS
Some people do not notice any symptoms of a ruptured eardrum. Others complain only after several days of general discomfort in their ear and feeling that ‘something is not quite right with the ear’. Some people are surprised to hear air coming out of their ear when they blow their nose. Forcefully blowing nose causes air to rise up to fill the space in the middle ear. Normally this will cause the eardrum to balloon outward. But if there is a hole in the eardrum, air will rush out. Sometimes the sound is loud enough for other people to hear.
Other symptoms of a ruptured eardrum include:
- Sudden sharp ear pain or a sudden decrease in ear pain
- Drainage from the ear that may be bloody, clear, or resemble pus
- Ear noise or buzzing
- Hearing loss that may be partial or complete in the affected ear
- Episodic ear infections
- Facial weakness or dizziness
DIAGNOSTIC EVALUATION
- Audiometry: this hearing test checks how sensitive ears are to sounds at different volumes. The hearing tests may include pure-tone audiometry and speech audiometry tests. The tests help measure the quietest sounds or speech that can hear. They also help measure how well one can understand words when they are spoken at a normal sound level. These tests may check the type of hearing loss.
- Otoscopy: an otoscope helps to see inside the ear and visualize the eardrum
- Tuning fork test: for this test, a vibrating tuning fork is held against the bone behind the ear. The tuning fork may also be held against the forehead, nose, or outside the opening of ear. You will be asked if you can hear certain sounds. Your hearing may be tested holding the tuning fork in more than one place. When this is done, you will be asked to state which area you heard the sound best.
MANAGEMENT
- Ear kept dry
- Oral or topical antibiotics
Often no specific treatment is needed. The ear should be kept dry, routine antibiotic ear drops are unnecessary. However, prophylaxis with oral broad-spectrum antibiotics or antibiotic ear drops is necessary if contaminants may have entered through the perforation as occurs in dirty injuries. If the ear becomes infected, amoxicillin 500 mg is given for 7 days. Although most perforations close spontaneously, surgery is indicated for a perforation persisting.
Surgical Management
Surgery is required to repair eardrum and prevent future ear infections. This is done when the hole in eardrum is large or does not heal on its own.
- Myringoplasty: this type of surgery uses a tissue graft to cover torn eardrum. A tissue graft may be taken from own body, another person, an animal, or is man-made. A procedure called a mastoidectomy may also be done with a myringoplasty. A mastoidectomy is removal of infected bone from behind ear.
- Tympanoplasty: this surgery repairs torn eardrum and any damage to inner ear. A tympanoplasty also helps prevent ear infections that stop and come back. The hole in eardrum will be covered with a tissue graft.
