What are the primary causes of adult perforated tympanic membrane (TM)?

Primary Causes of Adult Perforated Tympanic Membrane

The most common causes of adult tympanic membrane perforation are trauma (both blunt and penetrating), acute otitis media, and chronic otitis media, with trauma accounting for the majority of cases in adults. 1, 2, 3

Traumatic Causes (Most Common in Adults)

• Blunt trauma (56% of traumatic perforations) 4

  • Physical assault/direct blow to the ear
  • Blast injuries
  • Barotrauma (pressure changes during flying, diving)
  • Sports injuries

• Penetrating trauma (44% of traumatic perforations) 4

  • Ear canal cleaning with cotton swabs or other objects
  • Foreign body insertion
  • Iatrogenic causes (medical procedures)

Infectious Causes

• Acute Otitis Media (AOM)

  • Bacterial infection causing middle ear inflammation
  • Pressure buildup from purulent effusion can lead to spontaneous rupture
  • Perforation typically occurs as a local sequela of AOM 1

• Chronic Otitis Media

  • Persistent or recurrent middle ear infections
  • Leads to chronic perforation that typically will not heal without surgical intervention 3

• Otomycosis (Fungal Infection)

  • Can cause perforation through direct invasion of tympanic membrane
  • Initially appears as white opaque area on tympanic membrane before disintegration 5

Risk Factors for Perforation

• History of recurrent ear infections
• Eustachian tube dysfunction
• Immunocompromised status
• Previous tympanic membrane perforations
• Inadequate treatment of acute otitis media

Clinical Presentation

• Conductive hearing loss (typically mild, <30 dB)
• Aural fullness sensation
• Mild tinnitus
• Ear discharge (if infection present)
• Pain (more common with acute perforations)
• Vertigo, nausea, and vomiting (suggests possible ossicular chain disruption) 2

Diagnostic Approach

• Otoscopic examination to visualize perforation

  • Note size, location, and appearance of perforation
  • Carefully suction blood or purulent secretions if present
  • AVOID irrigation and pneumatic otoscopy as these can worsen injury 2

• Audiometric testing if significant hearing loss is present

  • Conductive hearing loss >30 dB suggests ossicular chain disruption
  • Sensorineural loss may indicate inner ear/nerve damage 2

Management Considerations

• Most small traumatic perforations heal spontaneously within 1-3 months 2, 3, 4
• Keep the ear dry to prevent infection
• Antibiotics (oral and/or topical) for perforations related to acute otitis media
• Surgical intervention (tympanoplasty) may be required for:
  • Perforations that don't heal after 3 months
  • Large perforations
  • Perforations from chronic otitis media
  • Cases with significant hearing loss 6, 2

When to Refer to Otolaryngology

• Traumatic perforations with vertigo or significant hearing loss
• Perforations from chronic otitis media
• Perforations from acute otitis media that don't heal within one month
• Continuous pain, facial paralysis, or other alarming symptoms 2, 3

Prognosis

• Excellent prognosis for traumatic perforations, with spontaneous healing in most cases
• Children show particularly good outcomes with 100% spontaneous healing reported in some studies 4
• Chronic perforations from infection typically require surgical intervention for closure 3