What is the management of tympanic membrane (TM) perforation?

Management of Tympanic Membrane Perforation

For tympanic membrane perforations, clinicians should prescribe a non-ototoxic topical preparation when treating associated infections and keep the ear dry to prevent complications while allowing for spontaneous healing in most cases. 1

Etiology and Presentation

• Tympanic membrane (TM) perforations typically result from trauma, acute otitis media, or chronic middle ear infections 2, 3
• Common symptoms include mild conductive hearing loss, aural fullness, and mild tinnitus 2
• Most traumatic perforations occur in young adult males, with domestic assault (28.3%), self-inflicted/accidental injuries (20.8%), and road traffic accidents (18.9%) being common causes 4

Initial Assessment

• Carefully suction blood, purulent secretions, and debris from the ear canal to visualize the perforation 2
• Document the size and location of the perforation - perforations are commonly found in the antero-inferior part of the TM (46.9%) 4
• Avoid irrigation and pneumatic otoscopy in cases of suspected perforation as these can worsen the injury or introduce infection 2, 1
• Consider tympanometry if swelling or discomfort don't preclude its use - a normal type A tracing suggests an intact tympanic membrane 1

Management Approach

Conservative Management

• Most small perforations resolve spontaneously within 1-2 months 2, 5
• Keep the ear dry to prevent infection - this is crucial since perforation predisposes to middle ear infections 3
• For traumatic perforations:
  • 93% heal spontaneously with conservative management 5
  • Children demonstrate complete spontaneous recovery in most cases 5

Medication Management

• For perforations associated with acute otitis externa (AOE):
  • Use only non-ototoxic topical preparations when the tympanic membrane is not intact 1
  • Ototoxic preparations can cause severe hearing loss after prolonged or repetitive administration 1
• For perforations with chronic suppurative otitis media:
  • Ofloxacin otic solution is FDA-approved: ten drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 6
  • The patient should lie with the affected ear upward during instillation 6
  • The tragus should be pumped 4 times to facilitate penetration into the middle ear 6

Surgical Management

• Consider surgical referral for:
  • Perforations that don't heal within one month 2
  • Traumatic perforations associated with vertigo or significant hearing loss 2
  • Chronic perforations due to chronic otitis media or cholesteatoma 3
• Surgical options include tympanoplasty, with success rates reported to be high 5
• Novel adjuvant treatments for enhancing TM perforation repair include:
  • Biomolecules to stimulate growth of perforation edges 1
  • Bioengineered scaffolds 1
  • Tissue-engineered myringoplasty with basic fibroblast growth factor (b-FGF) has shown 98.1% closure rate versus 10% with saline 1

Prognostic Factors

• Factors associated with poor healing outcomes:
  • Large perforation size 4
  • Penetrating injuries to the TM 4
  • Postero-superior location of the perforation 4
• Vertigo, nausea, vomiting, and conductive hearing loss >30 dB suggest disruption of the ossicular chain 2
• Profound sensorineural hearing loss may indicate inner ear or nerve damage 2

Special Considerations

• For diabetic patients or immunocompromised individuals with ear infections, consider atraumatic cleaning with aural suctioning under microscopic guidance 1
• In cases of fungal otitis externa (otomycosis) with TM perforation, topical antifungal therapy is recommended, with oral antifungals (voriconazole, posaconazole, or itraconazole) considered for refractory cases 1
• Avoid ear irrigation in patients with TM perforation as this can introduce infection and cause complications 1

Follow-up

• Regular follow-up is recommended until complete healing occurs, typically within 6-8 weeks 5
• ENT consultation is necessary when alarming signs exist, such as:
  • Continuous pain
  • Vertigo
  • Facial paralysis
  • Perforation that persists beyond the expected healing time 3