Tympanic Membrane Perforation
Tympanic membrane perforation can result from an infection, trauma, or even be part of a medical procedure. Perforations may be temporary or permanent, and their effects vary depending on their size, location, and any associated pathological conditions.
Causes of Tympanic Membrane Perforation
Infection is the leading cause of tympanic membrane perforation. Acute middle ear infection can lead to relative ischemia of the tympanic membrane, which, when combined with increased pressure in the middle ear space, may result in a tear or rupture of the membrane.
Traumatic perforations may occur from direct blows to the ear (e.g., being slapped or hit by a wave at the beach). Exposure to excessive atmospheric pressure, such as during an explosion, can also rupture the tympanic membrane. Divers are particularly susceptible due to water pressure, especially if they have a history of ear problems.
Attempts to remove earwax or clean the ears using water irrigation by untrained individuals can also result in tympanic membrane perforation.
Pathophysiology
The tympanic membrane tends to heal spontaneously. Even in patients with multiple perforations, it is common to find an intact eardrum. Sometimes, the membrane regenerates with only two of its three layers, making that area appear thinner.
A tympanic perforation increases susceptibility to infections if water enters through the external auditory canal—especially low surface tension water, such as soapy water. For this reason, using earplugs while showering is usually recommended, and water-based earwax removal is contraindicated.
Symptoms
Patients with tympanic membrane perforation may experience a whistling sound when sneezing or blowing their nose, hearing loss, and a greater tendency toward infections during upper respiratory tract colds or when water enters the ear. Muco-purulent or even bloody discharge from the ear may occur in both acute and chronic cases. Acute perforations tend to be painful, while long-standing perforations are usually painless.
Diagnosis
Most tympanic membrane perforations are diagnosed through otoscopy and, when necessary, otomicroscopy. These methods reveal the discontinuity in the membrane, the size of the perforation, and the condition of the middle ear mucosa.
Imaging tests are generally unnecessary, except when ossicular chain destruction is suspected or in the presence of chronic cholesteatomatous otitis media (presence of skin cells in the middle ear that can erode and destroy bone).
Other diagnostic tools include tympanometry and audiometry, the latter being essential for treatment planning.
Treatment of Tympanic Membrane Perforation
As mentioned, most tympanic membrane perforations tend to close on their own. Medical treatment focuses on controlling discharge, typically through antibiotic ear drops and, if necessary, oral antibiotics.
Surgical treatment is indicated in highly symptomatic patients and/or swimmers. Several surgical options exist, from least to most complex:
- Chemical cauterization of the perforation edges.
- Debridement of the edges and sealing with a small collagen patch.
- Debridement and sealing with a fat graft taken from the patient.
- Myringoplasty (Type I Tympanoplasty), currently the most commonly used method.
Complications of Tympanic Membrane Perforation
A persistent tympanic perforation may lead to chronic simple otitis media or chronic cholesteatomatous otitis media, and their associated complications such as hearing loss, facial paralysis, labyrinthine fistulas, or central nervous system infections, among others.