Tympanic Membrane Perforations

Traumatic Perforations

The TM can be injured in several different ways. The scenario involving a person cleaning the ear with an applicator or hairpin, which we described in the last chapter, is the first way—a direct, penetrating injury. Frequently, a second person inadvertently hits the elbow of our unfortunate ear hygienist to cause the injury. Another cause is an implosion of the drum by a striking force, such as a slap or fist to the ear. This type of perforation is usually anterior and inferior. An abusive family member may be involved, and sometimes, pathetically, the victim will try to hide any detail of the incident when presenting to the office. Diving and water skiing accidents may also implode the drum. Rarely, a forceful explosion near the ear can also implode the drum, usually causing acoustic damage to the inner ear as well. Finally, a hot slag particle, as with welding, may

Tympanic Membrane Perforations 55

penetrate the TM, cauterizing the edges as it goes through into the middle ear. In this case, spontaneous healing is less likely and recurrent infection and drainage may ensue.

Traumatic perforations vary in their size and location. Some may be difficult to see on examination. They may be small and hidden behind exu-dates or blood clots or may also be obscured by the bony hump of the anterior canal wall. If the examiner can see part of the drum, the pneumatic otoscope, with an adequate air seal in the canal, is the key to diagnosis. A totally immobile TM will be seen with any perforation. (An extremely scarred TM or glue ear may also show immobility). Conversely, if the drum is mobile, there is no perforation.

In all traumatic perforations, middle ear ossicle damage, even with oval or round window rupture, may occur. Look for inordinately large hearing loss (>35 dB HL) or the presence of vertigo as a clue. The Weber and Rinne tests are helpful here. Most traumatic perforations (probably 90%) heal spontaneously. Avoidance of water and observation are the only initial treatments needed. Topical antibiotic eardrops may be indicated if drainage and infection are present. Very large traumatic perforations and those from slag are less likely to heal. These will require surgery if they show no signs of closing after observation for a few months.

Perforations from Acute Infections

The most frequently occurring perforations are, thankfully, the most shortlived. These are the ones resulting from acute otitis media. Here, the TM is so red, wet, and distorted that the small opening is not always seen. Almost all of these heal within days, assuming that antibiotics are given. An exception occurs with the rare, aggressive, acute necrotizing otitis media. This is usually caused by beta streptococcus in conjunction with a severe viral infection like measles. In other countries, scarlet fever is still a cause. In these cases, a large permanent perforation is created. Necrosis of the central TM typically leaves a large horseshoe-shaped hole in the drum surrounding the manubrium. In the pre-antibiotic era this was one of the leading causes of chronic perforations.

Chronic Perforations

Long-standing perforations may be seen in patients who have experienced years of eustachian tube problems and intervening infections. Ventilating tubes may have been inserted repeatedly. The surrounding TM is often thick and scarred (Fig. 5.2). Affected individuals have conductive hearing loss and may be plagued with recurrent drainage through the perforation. These episodes of drainage (otorrhea) are often initiated by water in the ear or upper respiratory infections.

Fig. 5.2 Chronic otitis media with perforation and sclerosis of upper TM.

(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)

Fig. 5.2 Chronic otitis media with perforation and sclerosis of upper TM.

(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)

The exudates usually culture out the same organisms as seen in external otitis, namely Pseudomonas, Staphylococcus, Proteus, and Enterobacter. Incidentally, otorrhea from any middle ear infection may initiate external otitis, an exception to our statement that most ear problems involve only one "compartment."

Persistant or recurrent otorrhea through a perforation is known as chronic suppurative otitis media. Topical antibiotic/steroid eardrops can clean up the drainage. Tympanoplasty, surgical reconstruction of the TM (and eroded ossicles, if needed), may be performed if and when no infection is present. Often there is chronic mastoiditis in the adjacent cavity, and mastoidectomy may accompany the procedure.

With the emergence of AIDS in recent decades, tuberculous otitis media deserves mention. This very rare disorder usually starts with painless thickening of the TM followed by multiple perforations, with clear discharge. The hearing loss is inordinately large due to inner ear involvement with the bacillus. These findings should alert suspicion, and a positive culture for acid-fast organisms will confirm the diagnosis.

Scarring and Tympanosclerosis 57

Summary

Regarding perforations in general, the cause, as one can ascertain from the patient's history, determines the treatment and prognosis. Those of acute otitis media, if not the streptococcal necrotizing type, will heal, especially if the infection is cleared up with oral antibiotics. In fact, early antibiotics may help the necrotizing ones. Traumatic ones will also heal most of the time. Conservative observation, with water avoidance, is the usual initial treatment. If there is moist or purulent drainage from any perforation, antibiotic/steroid eardrops, preferably following a culture, will help. Large or chronic perforations, and those from slag burns, will probably need surgical repair. Do not forget to evaluate the hearing. A substantial loss (>35 dB HL) may indicate traumatic ossicular damage; this also will need surgical attention. Finally, multiple perforations may indicate tuberculosis, especially in the presence of AIDS. The primary practitioner may initiate treatment for all the types of perforations discussed so far, although elective ENT follow-up is recommended for all but the responsive acute otitis media. One should note that the perforations discussed so far occur in the "safe" central or anteroinferior part of the TM. There is a "dangerous" area for perforations at the posterior and superior margins of the drum. Here, there is a predisposition for the development of cholesteatoma (discussed later in this chapter), and early ENT referral, within a week, should be made.

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