What are the causes of tympanic membrane perforation?

Causes of Tympanic Membrane Perforation

Tympanic membrane perforations typically result from trauma, acute otitis media, and chronic middle ear infections, with additional causes including iatrogenic injuries during ear procedures. 1

Common Causes

• Infections:

  • Acute otitis media - can lead to spontaneous perforation when pressure from middle ear fluid buildup ruptures the tympanic membrane 1, 2
  • Chronic suppurative otitis media - responsible for 55.7% of perforations in some populations 2

• Trauma:

  • Direct trauma from foreign objects (including cotton-tipped applicators) 3, 1
  • Barotrauma (pressure injuries) from activities like flying, diving, or blast injuries 4
  • Slap injuries to the ear 1

• Iatrogenic causes:

  • Ear irrigation procedures - can cause perforation, especially with inappropriate technique or when performed on at-risk patients 5
  • Complications from ear syringing - reported in approximately 1 in 1000 cases 5
  • Oral jet irrigators used inappropriately in the ear 5

• Other causes:

  • Thermal or chemical burns to the ear canal 1
  • Radiation therapy affecting the ear canal (can lead to thinning of the tympanic membrane) 5

Risk Factors for Perforation

• Anatomical factors:

  • Atrophic areas of the tympanic membrane (more vulnerable to perforation) 5
  • History of previous ear surgery 5
  • Narrow ear canals (increases risk during procedures) 5
  • Exostoses or osteomas in the ear canal 5

• Medical conditions:

  • Diabetes (higher risk of complications from ear procedures) 5
  • Immunocompromised states 5
  • History of head and neck radiation 5

Clinical Presentation

• Common symptoms:

  • Mild conductive hearing loss 1, 2
  • Aural fullness 1
  • Mild tinnitus 1
  • Otorrhea (ear discharge) - present in 81.5% of cases in some studies 2
  • Otalgia (ear pain) - present in 72.8% of cases 2

• Warning signs requiring immediate attention:

  • Vertigo, nausea, and vomiting (may indicate ossicular chain disruption) 1, 6
  • Profound hearing loss (may indicate inner ear damage) 1
  • Facial paralysis 6
  • Continuous pain 6

Prevention of Iatrogenic Perforations

• Avoid ear irrigation in high-risk patients:

  • Patients with history of ear surgery 5
  • Known or suspected non-intact tympanic membrane 5, 3
  • Patients with diabetes (especially with tap water) 5

• Use appropriate techniques:

  • Consider manual removal methods instead of irrigation in high-risk patients 5
  • Use non-ototoxic preparations when treating ear conditions in patients with perforated eardrums 7, 3
  • Keep ears dry to prevent infection when perforation is present 3

Common Pitfalls to Avoid

• Never irrigate the ear canal when tympanic membrane perforation is present or suspected 3
• Avoid using cotton-tipped applicators in the ear canal as they may cause trauma 3
• Do not use alcohol-containing or potentially ototoxic preparations in ears with suspected perforation 3
• Avoid pneumatic otoscopy in cases of suspected perforation 1

Understanding these causes and risk factors is essential for both prevention and appropriate management of tympanic membrane perforations to minimize complications and optimize outcomes.