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Ear Drum Perforations: Doc, is there a hole in my ear drum?

Updated: Sep 2, 2021

Welcome back to our TGIF Dr Euan's blog, dear friends ๐Ÿ˜Š.


We are all happier now that we can go out for meals at our favourite restaurant or hawker centre and enjoy our Bak Chor Mee or Roti Prata! But do get vaccinated and continue to practice the safe distancing measures as we now face the Delta variant of the COVID -19 virus.


Today, let's look at another fairly common ENT problem we may encounter:


Q: What symptoms might I experience with an Ear Drum Perforation?


Perforations (holes) in the ear drum can cause a variety of symptoms, such as, hearing loss, tinnitus (ringing in the ears), ear discharge, a sense of "blocked ear " sensation, and rarely, ear pain / headaches. Simple ear drum perforations are not usually associated with vertigo / giddiness per se.


Q: What does an Ear Drum perforation look like?


Here is a schematic illustration to show you what a normal intact ear drum looks like versus what an ear drum perforation / rupture looks like:

Q: What causes Ear Drum perforations?

  1. Trauma: self inflicted eg cotton bud / Q tip cleaning injuries or accidental eg children playing with objects and even "playing doctor" on each other. So the ear drum can be ruptured if the instrument or Q tip is forced too deep into the ear canal.

  2. Baro-trauma: this is due to sudden / severe changes in the air pressure across the ear drum eg during descent during scuba diving or cabin pressure during air flight.

  3. Infection: this is the most common cause, and may start in early childhood with repeated middle ear infections, leaving a persistent perforation long term. Chronic Suppurative Otitis Media (CSOM) is still the leading cause of hearing loss and deafness in many countries around the world.

  4. Certain chronic ear conditions eg cholesteatoma which may be quiescent for many years; this condition slowly erodes the middle ear ossicles and other bony structures over time, and may even seed infection to the brain if untreated.

  5. Rarely, we get cases of granulomatous TB ear, which can present with multiple ear drum perforations. I have only seen 3 cases of TB ear in my career, but TB remains endemic in Singapore. This diagnosis needs a high index of suspicion and adequate sampling of tissue for culture confirmation which can take up to 6 -8 weeks.

Q: What should I do about the Ear Drum Perforation?


Do see your GP or ENT Specialist to check your ear and to confirm the diagnosis of ear drum perforation.


It is important to determine the size and type of ear drum perforation eg there are "safe" or central perforations (which form the majority of cases) and there are the "unsafe" or maginal perforations which may be linked to such conditions as cholesteatoma. Marginal perforations allow the ear canal skin to migrate and grow into the middle ear space, giving rise to cholesteatomas and can cause repeated infections.


Sometimes, we may take a swab for bacterial culture if there is active otorrhea (ear discharge) to determine the type of bacteria causing the infection and the best anti-microbial agent to use for effective treatment & eradication of the infection.


if there is an ear drum perforation seen, we will usually arrange for a Audiogram or Hearing assessment, as ear drum perforations usually result in a hearing loss, due to a disruption of the sound conduction, or what we term as a "Conductive" Hearing Loss.


For Tympanography, an impedance probe is also fitted into your ear canal to check on the ear drum / middle ear impedance to trace the movement of the ear drum; if there is a perforation, this will cause a "no seal" effect on the tympanogram tracing.



Q: What Treatment is available for Ear Drum perforations?


There are 2 main issues to consider in the treatment of ear drum perforations: hearing loss & infection


If the patient is not troubled by hearing loss and / or infections, then we may elect to observe the perforation and review once every 6 months. Small acute perforations may also heal themselves over time.


Medical Therapy:


If there is active ear infection / discharge, then you may be prescribed with a course of anti-biotic ear drops to treat the infection. Rarely, do we use oral anti-biotics unless it is a severe infection. The choice of anti-biotic is done in conjunction with the ear canal swab culture sensitivity report where available.


This treatment also helps to plan the timing of surgery to repair the ear drum perforation, as it is more successful to perform the surgery when there is no active infection.


Surgery:


The aim of surgery is to seal off the ear drum perforation, and to reduce the infection occurrence & improve the hearing. This may also help you return to your activities eg swimming / diving etc


In the past, we used to do such ear drum repair operations via post-auricular (from behind the ear) / end-aural (from in front of the ear) surgical incisions to gain access to the ear drum. We use the Operating Microscope to perform the surgery, the graft is usually a homo-graft of fascia or peri-chondrium harvested from around the ear.


Most surgical centres report a 80 to 90 percent success rate for myringoplasty to repair the ear drum perforation; the main reason for failure is infection resulting in the graft breakdown. So that is why we will prefer to time the surgery when there is no active ear discharge. If there is infection, we may treat the infection and delay the surgery for a better success rate.


Nowadays, we are using minimally invasive approaches eg Endoscopic Ear Surgery (EES) whereby we do the entire surgery endoscopically, which reduces post-operative pain and also a faster return to work and normal activities. You can refer to our clinic website for more detailed information on EES:


https://www.euansent.com/endoscopic-ear-surgery



For more information on ear drum perforation surgery / repair, you may want to check out some of these references below:

  • Verhoeff M. Chronic suppurative otitis media: A review. Int J Ped Oto. 70(1):1-12.

  • Webb B, Chang CYJ. Efficacy of Tympanoplasty without mastoidectomy for Chronic Superative Otitis Media. Arch of Otolaryngol Head and Neck Surg. 2008/11. 1155-1158.

  • Haynes DS, Harley DH. Surgical management of chronic otitis media: beyond tympanotomy tubes. Otolaryngol Clin North Am. 2002 Aug. 35(4):827-39. [Medline].

  • Prescott CAJ. Chronic otitis media(COM) โ€“ A personal philosophy. Int J Ped Oto. 2006. 70:1317-1320.

  • Adams ME and El-Kashlan HK. Tympanoplasty and Ossiculoplasty. Cummings CW et al (Eds). Otolaryngology: Head & Neck Surgery. 5th Edition. Philadelphia, PA: Mosby-Elsevier; 2010.

  • Sarkar S, Roychoudhury A, Roychaudhuri BK. Tympanoplasty in children. Eur Arch Otorhinolaryngol. 2009 May. 266(5):627-33. [Medline].

  • Hardman J, Muzaffar J, Nankivell P, Coulson C. Tympanoplasty for Chronic Tympanic Membrane Perforation in Children: Systematic Review and Meta-analysis. Otol Neurotol. 2015 Jun. 36 (5):796-804. [Medline].

  • Aggarwal R, Saeed SR, Green KJ. Myringoplasty. J Laryngol Otol. 2006 Jun. 120(6):429-32. [Medline].

  • Chang CYJ. Chronic Disorders of the Middle Ear and Mastoid (Tympanic Membrane Perforations and Cholesteatoma. Mitchell RB. Pediatric Otolaryngology for the Clinician. New York, NY: Springer; 2009.

  • Lin AC, Messner AH. Pediatric tympanoplasty: factors affecting success. Curr Opin Otolaryngol Head Neck Surg. 2008 Feb. 16(1):64-8. [Medline].

  • Wehrs RE. Grafting techniques. Otolaryngol Clin North Am. 1999 Jun. 32(3):443-55. [Medline].

  • Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009 Apr 15. 79(8):650, 654. [Medline].

  • Kartush JM, Michaelides EM, Becvarovski Z, LaRouere MJ. Over-under tympanoplasty. Laryngoscope. 2002 May. 112(5):802-7. [Medline].

  • Seiden AM et al. Functional Disorders. Otolaryngology: The Essentials.

  • Luetje III CM. Reconstruction of the Tympanic Membrane and Ossicular Chain. Bailey BJ. Head & Neck Surgery โ€“ Otolaryngology. 4th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

  • Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am. 2006 Dec. 39(6):1161-76. [Medline].

  • Wasson JD, Papadimitriou CE, Pau H. Myringoplasty: impact of perforation size on closure and audiological improvement. J Laryngol Otol. 2009 Sep. 123(9):973-7. [Medline].

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