Is trichloroacetic acid (TCA) application recommended for a small tympanic membrane perforation?

TCA Application for Small Tympanic Membrane Perforation

Trichloroacetic acid (TCA) application can be used as a chemical cauterization technique for small, persistent tympanic membrane perforations that fail to heal spontaneously, though this is not a first-line treatment and should only be attempted after the ear is completely dry and infection-free.

Initial Management Priority

Most small tympanic membrane perforations heal spontaneously without intervention, making watchful waiting the preferred initial approach 1, 2. The primary goals are:

• Keep the ear dry to prevent infection using ear plugs or petroleum jelly-coated cotton balls when showering, and avoid swimming until healed 1
• Avoid ear canal irrigation, which can cause middle ear infection, vertigo, or ototoxicity 1
• Avoid cotton-tipped applicators that may cause further trauma 1

When to Consider Chemical Cauterization

Chemical cauterization with TCA is reserved for specific clinical scenarios:

• Tiny persistent perforations that remain after initial healing or treatment of the underlying cause 3
• Small to moderate perforations that have failed spontaneous closure after appropriate observation period (typically one month) 2
• Perforations that have significantly reduced in size but have a small residual opening 3

Prerequisites Before TCA Application

Before attempting chemical cauterization, ensure:

• The ear must be completely dry with no active infection 4
• Underlying etiological factors (septal deviation, allergic rhinitis, chronic infection) have been treated 4
• The perforation is of the pars tensa (not marginal or attic perforations) 4

Evidence for TCA Use

The evidence supporting TCA application is limited but shows some utility:

• One case series reported successful closure of a tiny persistent perforation using trichloroacetic acid cauterization after the perforation had significantly reduced in size following treatment of fungal otitis externa 3
• Chemical cautery studies using 50% silver nitrate (not TCA specifically) with patching achieved 73.75% success rates for small to moderate perforations, with highest success in traumatic perforations 4

Important Caveats

This technique is not mentioned in current American Academy of Otolaryngology-Head and Neck Surgery guidelines 1, 5, suggesting it is not considered standard first-line management. The guidelines instead emphasize:

• Novel adjuvant treatments like biomolecules, bioengineered scaffolds, and tissue-engineered myringoplasty with basic fibroblast growth factor (98.1% closure rate) 5
• Surgical myringoplasty for perforations that fail conservative management 3, 4

Practical Algorithm

1. First 4 weeks: Observe for spontaneous healing while keeping ear dry 1, 2
2. If infection present: Use non-ototoxic topical fluoroquinolones (ofloxacin or ciprofloxacin-dexamethasone) for no more than 10 days 1
3. After 1 month: If small perforation persists and ear is completely dry, consider chemical cauterization as an alternative to immediate surgery 3, 4
4. If cauterization fails or perforation is moderate-to-large: Refer for surgical myringoplasty 2, 4

Chemical cauterization should be viewed as a time-tested but adjunctive technique 4, not a replacement for appropriate medical management or definitive surgical repair when indicated.