John E. Butler M.D.
Joshua Yorgason M.D.
Otolaryngology
Head & Neck Surgery
Otolaryngology
Hearing and Balance Disorders
between middle ear and the
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eMedicine Specialties >
Otolaryngology and Facial Plastic
Surgery > Middle Ear & Mastoid
Middle Ear,
Tympanic Membrane,
Perforations
Matthew L Howard, MD, JD, Head
and Neck Surgery (Retired), Kaiser
Permanente Medical Center, Santa
Rosa, California
Updated: Sep 25, 2009
Introduction
Tympanic membrane perforation
(TMP) is a condition as old as the
human species.
Problem
The tympanic membrane, also called
the eardrum (or just the drum), is a
stiff (but flexible), translucent,
diaphragmlike structure. The
eardrum moves synchronously in
response to variations in air
pressures, which constitute sound
waves. The drum's vibrations are
transmitted through the ossicular
chain to the cochlea. In the cochlea,
vibratory mechanical energy
changes to electrochemical energy
and streams via the eighth cranial
nerve to the brain. The tympanic
membrane and its attached ossicles
thus act as a transducer, changing
one form of energy into another form.
Tympanic membrane (TM) as
continuation of the upper wall
of external auditory canal
(EAC) with angle of incline up
to 45 degrees on the border
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EAC.
Tympanic membrane perforations
(TMPs) can result from disease
(particularly infection), trauma, or
medical care. Perforations can be
temporary or persistent. Effect varies
with size, location on the drum
surface, and associated pathologic
condition.
Frequency
Incidence of tympanic membrane
perforation (TMP) in the general
population is unknown. One survey
found that that 4% of a population of
Native American children had
tympanic membrane perforation
(TMP).[1 ] Another study found that
3% of children treated with
ventilation tubes had the
condition.[2 ]However, the incidence
in the general population has not
been studied. Even the exact
number of surgical tympanic
membrane perforation (TMP) repairs
performed each year is unknown.
Analysis of government statistics
indicates that perhaps 150,000
tympanoplasties are performed per
year in a population of 280 million.
Etiology
Infection is the principal cause of
tympanic membrane perforation
(TMP). Acute infection of the middle
ear may cause a relative ischemia in
the drum concurrent with increased
pressure in the middle ear space.
This leads to a tear or rupture of the
eardrum that is usually preceded by
severe pain. If the perforation does
not heal, it leaves a residual
tympanic membrane perforation
(TMP).
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A prominent school of thought now
advocates less aggressive use of
antibiotics. Those who hold this
position recognize that many
episodes of otitis media are caused
by viruses, so they resolve
spontaneously; advocates of this
position desire to slow emergence of
antibiotic-resistant bacterial strains.
Evidence is emerging that an
increased incidence of acute
mastoiditis is resulting from reduced
use of antibiotics.[3 ]Time will tell
whether increased incidence of
perforation and other complications
of otitis media, such as brain
abscess, meningitis, and septic
sigmoid sinus thrombosis, also
occur.
Ear canal infections rarely cause
tympanic membrane perforations
(TMP). When this occurs, it is often
associated with infection by
Aspergillus niger.
Traumatic perforations may result
from blows to the ear (eg, being
struck with the flat of the hand;
falling from water skis with the head
hitting the water surface, ear down).
Exposure to severe atmospheric
overpressure from an explosion can
tear the drum.[4 ]Tympanic membrane
perforation (TMP) from water
pressure occurs in scuba divers,
usually in a drum with atrophy from
previous disease. Objects used to
clean the ear canal can perforate the
drum.
Inexpertly performed irrigation of the
ear canal for wax can lead to
perforation. In some settings, when
irrigation for cerumen is relegated to
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medical assistants, otolaryngologists
may see 10-20 patients per year with
this injury. Evidence exists that such
perforations are less likely to heal
spontaneously.[5 ]Tympanic
membrane perforation (TMP) is
intentionally created whenever a
surgeon makes an incision in the
eardrum (myringotomy). When
pressure-equalizing tubes
(ventilating tubes) are placed, the
TMP purposely is held open. Failure
of surgically created openings to
heal when the tube extrudes results
in chronic tympanic membrane
perforation (TMP).
Pathophysiology
The eardrum tends to heal itself.
Even eardrums that have been
perforated multiple times often
remain intact. At times, a perforation
heals with a thin membrane
consisting only of mucosal and
squamous epithelial layers without a
fibrous middle layer. Such a
neomembrane may be so thin that it
can be mistaken for a perforation
instead of a healed perforation.
Neomembranes may retract deeply
into the middle ear, sometimes
making them more difficult to
distinguish from actual perforations.
Examination under the operating
microscope resolves ambiguity.
Deep retraction, especially in the
posterior superior quadrant of the
drum, may presage formation of
cholesteatoma.
The presence of perforation renders
the ear more susceptible to infection
if water enters the ear canal. If
bacteria-contaminated water passes
through the perforation, infection can
result. Water surface tension may
protect the ear from penetration
through a very small perforation.
This explains higher infection rates
from hair washing than from
swimming activities (ie, soap lowers
surface tension so water can enter
the middle ear). Presence of
perforation is an absolute
contraindication to irrigation for
cerumen removal. History of
perforation is also an absolute
contraindication unless personal
knowledge derived from prior
examination indicates an intact drum.
Presentation
Perforation symptoms may include
audible whistling sounds during
sneezing and nose blowing,
decreased hearing, and a tendency
to infection during colds and when
water enters the ear canal. Copious
purulent drainage, which may be
sanguineous in both acute and
chronic perforation, confirms both
perforation and infection. Ear canal
infections also can cause purulent
drainage, but usually in lesser
amounts. Perforations
uncomplicated by infection or
cholesteatoma are never painful.
Presence of pain should alert the
physician to a concurrent disease
process. Perforations accompanied
by otorrhea or cholesteatoma are
usually not painful.
Indications
Many persons live their lives with
tympanic membrane perforations
that are entirely without symptoms.
Repair of such lesions is usually not
indicated. Perforations may be
associated with recurrent infection
when exposed to water. In
swimmers, divers, and other water
sports enthusiasts, repair may be
indicated as a quality-of-life issue.
Hearing loss may be present,
especially with larger perforations,
and may be a reason for repair.
Because a risk to residual hearing
exists with every operation on the
ear drum, a risk-benefit analysis in
which the patient participates is
mandatory. For example, question
whether the person may be helped
just as much with use of a hearing
aid.
Relevant Anatomy
The tympanic membrane has 2
distinct zones. The larger of the 2
zones is the pars tensa. This zone
consists of a tough and resilient
fibrous layer with a diaphanous
mucosal layer inside and squamous
epithelium outside. The smaller zone
is the pars flaccida, which lies
superior to the suspensory ligaments
of the malleus and lacks a fibrous
layer. Perforations of this area often
are described as more frequently
associated with complications. This
is true if the definition of TMP
includes depressions of the drum
into the middle ear, forming saclike
structures (retraction pockets).
Clearly, such pockets are more often
associated with cholesteatoma
formation.
Behind (or medial to) the drum is the
middle ear. In front of the drum (or
lateral or exterior) is the ear canal.
The drum lies at an angle to the bore
of the ear canal, creating a vestibule,
which can retain cerumen or debris.
The malleus is invested by the
fibrous layer of the tympanic
membrane, securely incorporating it
within the drum.
Contraindications
Tympanic membrane perforation
(TMP) may be unilateral or bilateral.
Select the worse-hearing ear first
when performing bilateral tympanic
membrane perforation (TMP) repair.
If increased hearing loss
complications ensue, the betterhearing ear remains uninjured. For
the same reason, if tympanic
membrane perforation (TMP) is
present in a patient's single hearingcapable ear, only incipient lifethreatening complications justify
repair attempts.
Workup
John E. Butler M.D.
Joshua Yorgason M.D.
Otolaryngology
Head & Neck Surgery
Otolaryngology
Hearing and Balance Disorders
Imaging Studies
Radiography and MRI are of no
value unless the clinical picture
suggests ossicular destruction
and/or cholesteatoma.
Asymptomatic perforations,
especially if hearing is near normal,
require no imaging studies.
Other Tests
•
•
•
•
•
Most tympanic membrane
perforations (TMPs) are
diagnosed using routine
otoscopy.
Small perforations may
require otomicroscopy for
identification.
Some hearing screening
programs include middle ear
impedance testing.
Screening tympanometry
may reveal abnormalities
consistent with perforation.
Confirmation still requires
examination.
Always perform audiometry
upon initial TMP diagnosis
and again before any repair
attempt, whether in the
office or in the operating
room.
o Preoperative and
postoperative
audiography should
always be
performed. A major
conductive loss not
only alerts the
surgeon to the
possible existence
of ossicular lesions,
but documentation
of a preexisting
sensorineural
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o
hearing loss may
protect the surgeon
from later
allegations that the
surgery caused the
hearing loss.
Audiometry often
reveals normal
hearing. The
presence of mild
conductive hearing
loss is consistent
with perforation,
and a conductive
component of at
least 30 dB
indicates possible
ossicular
discontinuity or a
pathologic condition.
Diagnostic Procedures
In rare cases, otomicroscopy and
impedance studies still leave the
tympanic membrane perforation
(TMP) diagnosis questionable. To
provide evidence of perforation (in
the form of a stream of bubbles), fill
the ear canal with sufficient distilled
water or sterile saline to cover the
tympanic membrane and have the
patient perform the Valsalva
maneuver. A negative test result is
suggestive but not definitive. A
positive test result is caused only by
tympanic membrane perforation
(TMP).
Histologic Findings
In chronic tympanic membrane
perforation (TMP), squamous
epithelium is found adjacent to
middle ear mucosa and creates a
perforation edge with no raw surface.
Such healing of the perforation edge
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is undoubtedly a contributing factor
to perforation persistence.
Treatment
Medical Therapy
Medical therapy for perforations is
directed at controlling otorrhea. Take
into account ototoxicity risk from
topically applied eardrops when
treating ear infections concurrent
with tympanic membrane perforation
(TMP). Infection alone occasionally
can cause sensorineural hearing
loss. Clinical toxicity from eardrops
in the presence of ear infection has
not been demonstrated
unequivocally, although experiments
in animals clearly demonstrate a
correlation. Legal implications of
administration of ototoxic eardrops
preceding sensorineural hearing loss
are clear. For this reason, avoid
eardrops containing gentamicin,
neomycin sulfate, or tobramycin in
the presence of tympanic membrane
perforation (TMP). When they are
used, substitute a less toxic
alternative as soon as drainage and
mucosal edema begin to subside.
Avoiding contamination of the middle
ear space with water via the
tympanic membrane perforation
(TMP) is critical in minimizing
otorrhea from a perforation.
Systemic antibiotics are occasionally
used when controlling otorrhea from
a TMP. Antibiotics (eg, trimethoprimsulfamethoxazole, amoxicillin)
directed at typical respiratory flora
suffice in most cases. Overgrowth
with Pseudomonas aeruginosa or
resistant Staphylococcus aureus
may occur. Failure of drainage to
clear after several days' therapy may
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require alteration of therapy following
culture and sensitivity tests. A
tendency of the ear canal to
pseudomonad overgrowth indicates
that the most accurate testing can be
obtained by suctioning a culture
specimen (under microscopic control)
directly from the middle ear through
the perforation.
Under routine circumstances, the
surface tension of water may prevent
it from entering the middle ear
through a small perforation. The
addition of soap reduces the water
tension. The ear is therefore at
greater risk of infection during hairwashing or bathing than from plain
water.
Surgical Therapy
Treatment of tympanic membrane
perforation (TMP) falls into 3
categories. No treatment is
necessary for nonswimming patients
with minimal hearing loss and no
history of recurrent ear infection. A
hearing aid may prove the only
necessary treatment for patients with
symptomatic hearing loss but no
infection or swimming history. Two
options exist for patients who are not
in either category.
Office treatments
The first option is to perform one of
the available office treatments. Such
treatments have the best chance of
working when the perforation is
small and involves neither the umbo
nor the annulus. Several methods
apply.
The simplest, but least effective,
method is to cauterize the edges of
the tympanic membrane perforation
(TMP) with a caustic, such as
trichloroacetic acid (10% solution),
and then apply a small patch of
cigarette paper. This technique was
developed in the 1800s; it
presumably remains in the repertoire
because it sometimes works.
Mechanical stripping of the
perforation margin (with topical
anesthetic or without) before
applying the patch slightly increases
the success rate.
A fat-plug tympanoplasty can be
performed. Obtain a small plug of fat
from the postauricular sulcus with
the patient under local anesthesia.
Prepare the tympanic membrane
perforation (TMP) by anesthetizing
its margins with carefully applied
phenol solution. Next, mechanically
débride the edges with microcup
forceps. The fat is then tucked into
the perforation, extending both into
the canal and into the middle ear
space.
The paper-patch method has a
reported success rate of 67%; the
fat-plug tympanoplasty of 87%.[6 ]
Another successful office treatment,
which has the major disadvantage of
requiring 6-10 weekly postsurgical
office visits, is the irritant oil method.
In this method, freshen the
perforation by stripping the margin
using microcup forceps. Performed
carefully, this can often be
accomplished without anesthetic. If
necessary, use a small amount of
phenol solution for anesthesia. Apply
a cotton ball that is 1-2 mm larger
than the diameter of the perforation
to the tympanic membrane
perforation (TMP). The patient then
instills a solution of irritative and
aromatic oils daily into the ear. The
solution is dispensed in 30-mL
dropper bottles and is formulated by
the pharmacy (all substances United
States Pharmacopoeia [USP] grade)
as 2 mL eucalyptol, 1.10 mL methyl
salicylate, 0.39 g thymol, 0.455 g
menthol, 1.20 mL oil of orange,
20.25 g sifted powdered sodium
borate, 20.25 g powdered boric acid,
60 mL of 90% ethyl alcohol, saffron
to suit for color, and water in a
sufficient quantity to make 5000 mL.
Change the cotton weekly. Repeat
edge freshening if no progress is
seen.
This nonsurgical method was initially
reported to have a 70% success rate,
and this author has obtained similar
results using it as the sole therapy
for perforations occupying less than
25% of the drum area.[7,8 ]
Other recently reported forms of
office treatment use fibrin glue or a
patch composed of a hyaluronic acid
ester and a dressing component.
The use of basic fibroblast growth
factor with a proprietary patch that
consists of a silicone layer and
atelocollagen has been described.
Excellent success has been reported,
but with very small numbers of
patients. Time will tell if these new
techniques will prove useful
additions to treatment options.
Tympanoplasty
The second option is to perform
tympanoplasty with the patient under
local or general anesthesia. An
incision may be made behind the ear
or entirely through the ear canal,
depending on the location and size
of the tympanic membrane
perforation (TMP). Repair requires
preparation of a suitable bed for
placement of a graft. By far, the most
commonly used grafting material is
postauricular fascia. Allograft
tympanic membranes obtained from
cadavers, once abandoned because
of fear of transmitting viral
pathogens, are again being used.
Other substances, such as the
urinary bladder matrix, are being
evaluated.[9 ]Grafts may be placed
medially or laterally to the perforation,
or in a combined position.[10 ]Surgeon
preference plays a part in these
decisions and in decisions
concerning the technical problems
associated with size and location of
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Joshua Yorgason M.D.
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Hearing and Balance Disorders
the perforation and the shape, angle,
and bore of the ear canal.
Tympanoplasty successfully closes
the tympanic membrane perforation
(TMP) in 90-95% of patients.
Fortunately, second and third
operations succeed in more than
90% of the remaining patients.
Consequently, fewer than 1 per 1000
persons still has tympanic
membrane perforation (TMP) after 3
operations.
Preoperative Details
Preoperative preparation of the ear
for surgery consists of eliminating
infection whenever possible.
Preoperative preparation of the
patient includes convincing the
smoker to stop during the immediate
postoperative period.
Follow-up
Risk of cholesteatoma formation,
either through the natural course of
the disease or from squamous
epithelium trapped during treatment,
requires regular follow-up care for all
patients postoperatively. Several
annual visits should be the minimum
once tympanic membrane
perforation (TMP) healing is verified.
Untreated tympanic membrane
perforation (TMP) may not require
regular follow-up care if a patient can
be relied upon to seek medical
advice if hearing changes or
persistent drainage from the ear is
noted. Location of the tympanic
membrane perforation (TMP)
informs the timing and frequency of
follow-up care. Perforations in the
pars tensa (stiff portion of the drum)
rarely lead to complications.
Intraoperative Details
The first known incident of
tympanoplasty performed on the
wrong ear occurred in 2004.
Surgeons are therefore advised to
adopt methods similar to those used
in other fields, and mark the ear to
be operated upon with ink while the
patient is awake and able to confirm
the accuracy of the selection.
Postoperative Details
Postoperative care is identical for
office treatment and operating room
repair techniques. Instruct patients to
keep water out of their ears. When
incisions and ear canal packing are
present, use protective dressings,
which are commercially available.
Otherwise, silicone rubber plugs
(also commercially available) or
cotton balls waterproofed with a little
petroleum jelly suffice.
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The exceptions are pars tensa
perforations located at the annulus
or rim of the tympanic membrane.
Tympanic membrane perforations
(TMPs) in this location are at risk of
developing middle ear
cholesteatoma from migration of
surface epithelium into the middle
ear. Perforations in the pars flaccida
(the portion without a fibrous center
layer) are more frequently
associated with complications and
require more frequent follow-up care.
Each operation carries a risk of
exacerbating hearing loss. Exact
incidence of such hearing loss is
unclear, with reported rates varying
widely in the medical literature. In
one series, approximately 1 per 500
operations resulted in much worse
hearing. In another, the rate was
nearly 2% for some degree of loss.
Of 1000 patients, expect one to
experience a perforation and 4 to
endure lost hearing. In a small group
of patients, persistent eustachian
tube dysfunction leads to late
complications, such as
cholesteatoma, reperforation, or
middle ear effusion. When the
underlay technique of tympanoplasty
is used, incidence of intratympanic
cholesteatoma is less than
1%.[6 ]These complications each
require unique treatment.
Outcome and
Prognosis
Uncomplicated tympanic membrane
perforation (TMP) requires no
treatment. Perforations remain
stable, and prognosis for absence of
morbidity is good. Repaired drums
reperforate in as many as 10% of
patients. Potential for late perforation
and the potential for formation of
cholesteatoma mandate regular
follow-up care for many years after
apparently successful surgery.
For excellent patient education
resources, visit eMedicine's Ear,
Nose, and Throat Center. Also, see
eMedicine's patient education article
Perforated Eardrum.
Multimedia
Complications
continuation of the upper wall
Media file 1: Tympanic
membrane (TM) as
of external auditory canal
(EAC) with angle of incline up
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to 45 degrees on the border
perforations. Otolaryngol
Head Neck
Surg. Mar 2008;138(3):3536. [Medline].
between middle ear and the
EAC.
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Joshua Yorgason M.D.
Otolaryngology
Head & Neck Surgery
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Hearing and Balance Disorders
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Keywords
middle ear perforations, tympanic
membrane perforations, tympanic
membrane perforation, middle ear,
eardrum, ear, perforated eardrum,
middle ear perforation, eardrum
perforation, tympanic membrane,
perforated eardrum, eardrum, ear
drum, tympanic membrane
perforations, TMP, eardrum
perforation, drum perforation,
tympanoplasty, ear infection, ear
Old Farm Professional Plaza
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perforation, middle ear infection,
myringotomy, otoscopy,
otomicroscopy
Contributor
Information and
Disclosures
Author
Matthew L Howard, MD, JD, Head
and Neck Surgery (Retired), Kaiser
Permanente Medical Center, Santa
Rosa, California
Matthew L Howard, MD, JD is a
member of the following medical
societies: American Academy of
Otolaryngology-Head and Neck
Surgery, American College of Legal
Medicine, and American College of
Surgeons
Disclosure: Nothing to disclose.
Managing Editor
Gerard J Gianoli, MD, Clinical
Associate Professor, Department of
Otolaryngology-Head and Neck
Surgery, Tulane University School of
Medicine; Vice President, The Ear
and Balance Institute; Chief
Executive Officer, Ponchartrain
Surgery Center
Gerard J Gianoli, MD is a member of
the following medical societies:
American Academy of
Otolaryngology-Head and Neck
Surgery, American College of
Surgeons, American Neurotology
Society, American Otological Society,
Society of University
Otolaryngologists-Head and Neck
Surgeons, and Triological Society
Disclosure: Nothing to disclose.
CME Editor
Medical Editor
Carol A Bauer, MD,
FACS, Associate Professor of
Surgery, Division of OtolaryngologyHead and Neck Surgery, Southern
Illinois University School of Medicine
Carol A Bauer, MD, FACS is a
member of the following medical
societies: American Academy of
Otolaryngology-Head and Neck
Surgery, American Neurological
Association, and Society of
University Otolaryngologists-Head
and Neck Surgeons
Disclosure: Nothing to disclose.
Christopher L Slack,
MD, Otolaryngology-Facial Plastic
Surgery, Private Practice,
Associated Coastal ENT; Medical
Director, Treasure Coast Sleep
Disorders
Christopher L Slack, MD is a
member of the following medical
societies: Alpha Omega Alpha,
American Academy of Facial Plastic
and Reconstructive Surgery,
American Academy of
Otolaryngology-Head and Neck
Surgery, and American Medical
Association
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PhD, Senior Pharmacy Editor,
eMedicine
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Chief Editor
Arlen D Meyers, MD,
MBA, Professor, Department of
Otolaryngology-Head and Neck
Surgery, University of Colorado
School of Medicine
Lone Peak Medical Campus
74 East 11800 South. #360
Draper, UT 84020
Arlen D Meyers, MD, MBA is a
member of the following medical
societies: American Academy of
Facial Plastic and Reconstructive
Surgery, American Academy of
Otolaryngology-Head and Neck
Surgery, and American Head and
Neck Society
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