What's the next step for a child with a persistent and enlarging eardrum (tympanic membrane) perforation after surgical removal of a tympanostomy tube?

Management of Persistent and Enlarging Tympanic Membrane Perforation After Tympanostomy Tube Removal

This child requires prompt otolaryngology evaluation for surgical repair (myringoplasty or tympanoplasty), as an enlarging perforation after tube removal will not close spontaneously and risks further complications including hearing loss and chronic infection. 1

Immediate Next Steps

Urgent ENT Referral

• Schedule evaluation within 2-4 weeks given the progressive enlargement of the perforation 1
• The fact that the perforation is actively enlarging (rather than stable) indicates it will not heal spontaneously and requires surgical intervention 1, 2
• At age 2 years, spontaneous closure is less likely than in older children, and enlarging perforations have essentially no chance of spontaneous resolution 2, 3

Pre-Surgical Assessment Required

• Audiometric testing to document current hearing status and degree of conductive hearing loss 1
• Otoscopic examination to assess perforation size, location, and any signs of squamous epithelial ingrowth (a serious complication requiring more extensive surgery) 4
• Evaluation for active infection or otorrhea, which must be treated before surgical repair 1, 5

Surgical Management

Timing Considerations

• Surgery should occur within 3-6 months of confirming the perforation is persistent and enlarging 1
• Earlier intervention is warranted if there is documented hearing loss, recurrent infections, or signs of epithelial migration 1, 4
• Delaying surgery risks further enlargement and potential complications like cholesteatoma formation from squamous epithelial ingrowth 4

Surgical Options

• Myringoplasty or tympanoplasty are the standard procedures with 80-90% success rates for closure with a single outpatient procedure 1
• The specific technique depends on perforation size and location, determined by the surgeon at evaluation 1
• These are typically outpatient procedures performed under general anesthesia 1

Critical Pitfalls to Avoid

Do Not Adopt "Watchful Waiting"

• While watchful waiting is appropriate for stable perforations that might close spontaneously, an enlarging perforation requires intervention 1, 2
• The 1-3% rate of persistent perforation cited in guidelines refers to stable perforations, not progressive ones 1
• Approximately 10% of perforations after tube removal require surgical closure, and enlarging perforations fall into this category 2, 6

Monitor for Complications While Awaiting Surgery

• Keep the ear dry - water precautions are essential with a perforation to prevent infection 7
• Treat any otorrhea immediately with topical antibiotic drops (ofloxacin otic solution is FDA-approved for perforated tympanic membranes) 5
• Watch for signs of squamous epithelial ingrowth, which appears as white debris or keratin accumulation and requires more extensive surgical management 4

Special Considerations for This Age Group

Age-Specific Factors

• At 2 years old, this child is at higher risk for persistent perforation compared to older children 2
• The indication for original tube placement (recurrent infection) and need for surgical tube removal are additional risk factors for persistent perforation 2
• Successful surgical repair at this age has excellent outcomes, with hearing typically returning to normal 1

Developmental Impact

• Hearing preservation is critical at this age for speech and language development 8
• Even temporary conductive hearing loss from the perforation can affect developmental milestones 8
• This urgency supports earlier rather than later surgical intervention 1, 8

Expected Outcomes

• Single-procedure success rate of 80-90% for perforation closure 1
• Hearing typically returns to normal after successful repair 1
• Risk of recurrent perforation after successful repair is low 1
• Long-term hearing outcomes are excellent when repair is performed promptly 1