Timothy C. Hain, MD Page last modified: March 3, 2012
The tympanic membrane (TM), also known as the ear drum, is located between the ear canal and the middle ear. Normally it completely separates these two spaces, preventing air or fluid from moving across these two spaces.
Perforations are holes in the TM. The most common causes are otitis media and trauma, including surgical injury. An example of a surgical perforation is a ventilation tube.
|Figure 1. Tympanostomy tube (T-tube) -- the small blue piece -- being placed in a ear drum|
Lou et al (2012) provided an fascinating breakdown of the causes of traumatic TM perforation in Zhejiang China. Compression injury was the cause in most of the patients. Of these, 52% were due to a slap or fist from a spouse or lover, 3% from parents or siblings, 4% from school teachers, 12% from schoolmates, state police and prisoner (7%), and a blow to the ear during a street fight (22%). They conclude that "In our experience, domestic violence and street fight were the most common causes of the traumatic TM perforation."
For the most part, perforations are annoyances. The are associated with slightly reduced hearing, there can be drainage, and they provide a portal for infections to enter the middle ear -- which functionally is similar to a sinus. Substances in the middle ear can go down the eustachian tube into the throat.
There are some good things about perforations too. They prevent pressure trauma, and can be used in persons who have symptoms when they fly.
Quite a bit can be done in the office without needing admission to the hospital or use of an operating room. These procedures are generally only done by otolaryngologists who specialize in ear disease (Otologists).
During the first 24 hours, the ear should be cleaned using an examining microscope. If necessary, block with local anesthestic and evert the epithelial edges of the perforations. A paper patch or splint may be used. To avoid infection, the patient shold avoid water from getting into the ear. Antibiotic packing and/or oral antibiotics may be helpful. To keep the ear dry, a hairdryer or boric acid powder may be used (Farrior, 2000).
About 90-95% of these perforations heal spontaneously within 3-4 months. When a paper patch is used, allow it to separate spontaneously. Surgery may be offered at 6-months for those that fail to heal.
If there is an infection, efforts should first be made to control the it using cleaning and antibiotics. Again, the ear needs to be kept dry using strategies such as a hairdryer, boric acid powder, and periodic cleaning (Farrior, 2000). After infection is controlled, there should be spontaneous healing within 6-12 weeks.
If there is no spontaneous healing, and there are no contraindications to surgery such as poor eustachian tube function or multiple PE tubes, then an effort may be made to close the perforation with surgery. This can sometimes be done in the office by cauterizing the margin of the perforation with acid, use of a paper patch, and continued efforts to keep the ear dry.
Perforations usually heal spontaneously after a few weeks. When they don't heal by themselves, a surgical procedure can be used to close the perforation (Tympanoplasty or office procedures such as noted above).
Healing of perforations is delayed by steroid drops, such as hydrocortisone drops. There is also delay in healing when drops containing antibiotics and steroids, such as "cipro/dexamethasone" are used. Drops such as "ofloxacin" do not contain steroids, and do not impair healing.
It is generally thought best not to use ototoxic ear drops in persons with perforations, as the drops may damage the inner ear.