A Review of Traumatic Tympanic Membrane Perforations
Introduction
Traumatic tympanic membrane perforations are the result of a direct hit to the external portion of the ear. This type of mechanism is typically seen in boxing (1). The rupture occurs from barotrauma in scuba diving or altitude change (3). The direct blow to the ear causes an increase in pressure in the ear canal leading to a perforation (4). The tympanic membrane is also known as the eardrum and is considered the transition point from the external to inner ear (2). The membrane itself is a three-layer structure that is anchored to the medial aperture of the ear canal (3). After trauma, the remodeling of the tympanic membrane following rupture is a complex process that involves epithelial cell migration, fibroblast increase, and tissue remodeling (1).
Image of the tympanic membrane rupture (9)
Diagnosis
Patients typically complain of an acute blunt trauma, a penetrating injury, or a barotrauma injury (4). A tympanic membrane injury typically leads to a conductive hearing loss that correlates with the size of the perforation (4). A sensorineural hearing loss is seen less commonly, secondary to displacement of the stapes (5). Patients can also complain of ear pain, temporary vertigo, and tinnitus (8).
Otoscope visualization of the tympanic membrane (2)
Treatment
Non-operative treatment has been shown to heal spontaneously in up to 80% of patients (2). Patients should be advised to try and keep the ear dry and not allow any water in the ear canal (3). Risk factors for failure of spontaneous healing include a large perforation and a peripheral location of the perforation (2). In order to facilitate healing, some ENT’s place a paper patch over the edge of the perforation and some will apply fibroblast growth factor to the perforation (4). Systemic antibiotics should be used if there is a water-sport injury or penetrating injury (8).
In patients who fail to have a spontaneous closure within three to six months, they will be a candidate for myringoplasty, which has a 90% success rate (4). An unrepaired membrane can lead to the development of a cholesteatoma or permanent hearing loss (5).
Conclusion
A traumatic tympanic membrane perforation is the result of barotrauma to the membrane, typically from direct trauma to the ear or a blast. They are diagnosed clinically, as the perforation can be visualized with an otoscope. There are adjuvant therapies to help facilitate treatment including paper patching and fibroblast injection. However, most will heal spontaneously. If nonoperative treatment fails, then a myringoplasty can be performed.
By Gregory Rubin, DO
rubinsportsmed.com
References
1) Lou, Zhengcai, et al. “Analysis of the Effectiveness of Basic Fibroblast Growth Factor Treatment on Traumatic Perforation of the Tympanic Membrane at Different Time Points.” American Journal of Otolaryngology, vol. 33, no. 2, 2012, pp. 244–49. PubMed, https://doi.org/10.1016/j.amjoto.2011.07.006.
2) Lou, Zheng-Cai, et al. “Traumatic Tympanic Membrane Perforations: A Study of Etiology and Factors Affecting Outcome.” American Journal of Otolaryngology, vol. 33, no. 5, 2012, pp. 549–55. PubMed, https://doi.org/10.1016/j.amjoto.2012.01.010.
3) Osetinsky, L. Mariel, et al. “Sport Injuries of the Ear and Temporal Bone.” Clinics in Sports Medicine, vol. 36, no. 2, Apr. 2017, pp. 315–35. PubMed, https://doi.org/10.1016/j.csm.2016.11.005.
4) Sagiv, Doron, et al. “Traumatic Perforation of the Tympanic Membrane: A Review of 80 Cases.” The Journal of Emergency Medicine, vol. 54, no. 2, Feb. 2018, pp. 186–90. PubMed, https://doi.org/10.1016/j.jemermed.2017.09.018.
5) Isaacson, Glenn. “Traumatic Tympanic Membrane Perforation.” Visual Journal of Emergency Medicine, vol. 21, Oct. 2020, p. 100892. ScienceDirect, https://doi.org/10.1016/j.visj.2020.100892
6) El-Anwar, Mohammad Waheed, et al. “Platelet-Rich Plasma Myringoplasty: A New Office Procedure for the Repair of Small Tympanic Membrane Perforations.” Ear, Nose, & Throat Journal, vol. 96, no. 8, Aug. 2017, pp. 312–26. PubMed, https://doi.org/10.1177/014556131709600818
7) Simani, Liam, et al. “Paper Patching Versus Watchful Waiting of Traumatic Tympanic Membrane Perforations: A Meta-Analysis.” The Laryngoscope, vol. 131, no. 9, Sept. 2021, pp. 2091–97. PubMed, https://doi.org/10.1002/lary.29580
8) The Atlas of Emergency Medicine, 5e | AccessMedicine | McGraw Hill Medical. https://accessmedicine.mhmedical.com/book.aspx?bookID=2969. Accessed 10 July 2023
9) Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4e | AccessMedicine | McGraw Hill Medical. https://accessmedicine.mhmedical.com/book.aspx?bookID=2744. Accessed 10 July 2023
