Definition and Frequency
The eardrum is a thin but resilient membrane that separates the outer ear canal from the middle ear and transmits the vibrations created by sound to the chain of hearing bones. Eardrum perforation (tympanic membrane perforation) is a condition in which the integrity of this membrane is disrupted, creating an opening between the outer ear canal and the middle ear. A hole in the drum can develop at any age as a result of infection, trauma or pressure changes, and it is a problem frequently encountered in ENT practice. While a small, fresh hole is very likely to close on its own, holes that are large, long-standing or infected are more likely to become permanent.
An intact eardrum matters not only for hearing but also for protecting the middle ear from water and microorganisms. When there is a hole, the middle ear is in direct contact with the outside environment; this can pave the way for recurrent infections.
Symptoms
A perforation usually begins with sudden, sharp ear pain; at the moment the drum perforates, the pain may ease quickly as the pressure is released. Bloody or purulent discharge may accompany the perforation or appear afterwards. Reduced hearing occurs to varying degrees depending on the size of the hole and the presence of fluid or blood in the middle ear. Some patients may also have ringing in the ear (tinnitus) and brief dizziness; dizziness developing particularly after a sudden pressure change or trauma may indicate that the inner ear has also been affected and should be evaluated carefully.
In perforations caused by infection, ear pain, fever and a feeling of fullness are usually experienced first; when the drum perforates on its own, the pain eases markedly along with the discharge. In traumatic perforations, sudden, sharp pain and sometimes hearing loss are to the fore. If findings such as severe dizziness, facial weakness or progressive hearing loss accompany it, a physician should be seen urgently.
Causes and Risk Factors
One of the most common causes of eardrum perforation is acute or chronic middle ear infection; during infection, pus accumulating in the middle ear can perforate the drum because of increased pressure. Traumatic causes include a direct blow to the ear, incorrect use of cotton swabs or similar objects while cleaning the ear, explosions or very loud noise (acoustic trauma), blows that create a sudden pressure change such as a slap, and barotrauma during diving or air travel.
Hot metal particles spattering during welding or chemicals getting into the ear, temporal bone fractures resulting from head injuries and, in some cases, previous ear surgery can also disrupt the integrity of the drum. Frequent middle ear infections, a permanent hole developing after long-term ear tube use, and Eustachian tube dysfunction are among the factors that increase the risk of the hole becoming permanent.
Diagnosis
The diagnosis is made by a detailed ear examination with a microscope or endoscope. The examination assesses the location and size of the hole, the condition of its edges and the appearance of the middle ear lining. If there is discharge or blood, the ear canal is first gently cleaned so that the drum can be seen fully. Audiometry is performed to determine the degree of hearing loss; this test also gives an idea of whether the inner ear has been affected.
Tympanometry is used to assess middle ear pressure and the mobility of the drum, but when a large hole is present, measurement is usually not possible. In cases with dizziness after trauma, sudden hearing loss or suspected head injury, computed tomography of the temporal bone and, where necessary, additional vestibular (balance) tests may be requested. If a chemical or thermal injury is suspected, the extent of middle ear damage is assessed separately.
Treatment Options
Conservative Approach
A significant proportion of fresh, small traumatic perforations can close on their own within a few weeks to a few months when the ear is kept dry and infection is prevented. During this period, keeping water out of the ear, avoiding forceful nose-blowing and, if considered necessary, the use of prophylactic antibiotic drops are recommended. The closing process is monitored with examinations at regular intervals. In perforations caused by infection or large perforations, the likelihood of spontaneous closure is lower and they usually become permanent.
Surgical Treatment: Tympanoplasty
Tympanoplasty is performed for holes that have not closed after a period of observation or that are judged to be permanent from the outset. In this operation, the hole is closed using the patient’s own tissue, usually cartilage from around the outer ear or muscle membrane (fascia), as the graft material. In suitable cases, the procedure can be performed endoscopically, entirely through the ear canal, without any incision behind the ear; this approach can make recovery easier. In experienced hands, the success rate of tympanoplasty is quite high. The main aims of the operation are to isolate the middle ear from the outside environment to prevent recurrent infections, to make the ear resistant to water and, as far as possible, to improve hearing.
Recovery and Follow-up
Both during spontaneous healing and after surgery, keeping the ear dry for a certain period is very important; using earplugs while showering and swimming is recommended. For a few weeks after surgery, you may be asked to avoid forceful nose-blowing, strenuous exercise and air travel. The graft usually takes a few weeks to take hold; during this period, healing is assessed with regular check-ups.
Hearing becomes clear once the swelling subsides and the graft has fully settled; most patients experience a marked gain in hearing. If discharge, fever, increasing pain or unexpected hearing loss develops after surgery, a physician should be seen without waiting for the scheduled check-up. In the long term, preventing recurrent upper respiratory infections and water getting into the ear is important for the durability of the repaired drum.
Precautions in Daily Life
For patients with an eardrum perforation, the most important precaution during healing is keeping the ear dry. When showering or washing hair, cotton wool with petroleum jelly or special earplugs can be used to keep water out of the ear. Avoiding activities such as swimming, diving and water slides until healing is complete is recommended. Since pressure changes during air travel can also place extra strain on the drum, patients planning to travel should discuss this with their physician in advance.
Treating conditions that cause nasal congestion, such as allergic rhinitis or sinusitis, is beneficial for supporting Eustachian tube function and aiding the healing of the drum. Reducing exposure to cigarette smoke also has a positive effect on both the healing process and the long-term health of the drum. In children, investigating causes underlying recurrent perforations, such as enlarged adenoids or frequent upper respiratory infections, can help prevent similar problems in the future.
Who Should Be Evaluated
Anyone who experiences discharge, bleeding or sudden hearing loss after sudden ear pain should see an ENT specialist, even if the complaints seem mild. Particularly in people who do water sports, have frequent ear infections or work in noisy environments because of their occupation, checking the health of the eardrum at regular intervals helps a possible perforation to be noticed at an early stage. In children, since they may not describe pain clearly, it is important to pay attention to indirect signs such as constantly fiddling with the ear, fever, restlessness or reduced response to sounds. In addition, in patients with a past history of recurrent eardrum perforation, investigating the underlying chronic middle ear problem separately is valuable for preventing similar problems in the future.
Frequently Asked Questions
Does every hole in the eardrum require surgery? No; small, fresh traumatic holes often close on their own when the ear is kept dry. Surgery comes into consideration for holes that do not close on their own or become permanent.
Do I need to go to hospital urgently when the drum perforates? If there is severe pain, bleeding, dizziness or sudden hearing loss, evaluation should not be delayed; even with mild symptoms, an ENT examination is recommended as soon as possible.
Does hearing return completely to normal after tympanoplasty? Most patients experience a marked gain in hearing, but the result may vary depending on the condition of the hearing-bone chain and the inner ear.
Is the operation done through an incision behind the ear? In suitable cases, the procedure can be performed endoscopically, entirely through the ear canal, without an incision; however, in some cases the classic approach may be preferred.
What happens if a hole in the drum is not treated? A permanent hole can lead to recurrent infections, permanent hearing loss and sensitivity to water; in some cases it can pave the way for the development of cholesteatoma.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.