What should be done for a patient with an expanding eardrum (tympanic membrane) perforation and hearing loss after a tympanostomy tube was removed and the hole did not close?

Management of Expanding Tympanic Membrane Perforation After Tube Removal

This patient requires urgent referral to an otolaryngologist within 1-2 weeks for evaluation and likely surgical repair, given the expanding perforation and associated hearing loss. 1

Immediate Actions and Timeline

Urgent Otolaryngology Referral

• Refer to an ENT specialist within 3 months maximum, but given the expanding nature and hearing loss, aim for 1-2 weeks. 1
• The expanding perforation indicates the tympanic membrane is not healing spontaneously and requires specialist intervention to prevent further complications. 1
• Hearing loss associated with the perforation significantly impacts quality of life and warrants expedited evaluation. 1

Audiologic Assessment

• Obtain formal audiometry at least 6 weeks after the tube was removed to document the degree of hearing loss. 1
• This baseline hearing test is essential for surgical planning and monitoring outcomes. 1
• Progressive hearing improvement can occur over the first postoperative month as middle ear inflammation subsides, so earlier testing may underestimate actual hearing status. 1

Ear Protection Until Repair

Water Precautions

• Keep the ear completely dry to prevent middle ear infection. 2
• Use earplugs or cotton balls coated with petroleum jelly when showering. 2
• Absolutely avoid swimming until the perforation has healed. 2

Avoid Trauma

• Do not use cotton-tipped applicators in the ear canal as they may cause further trauma or enlarge the perforation. 2
• Avoid any ear irrigation, as this can lead to middle ear infection, vertigo, or ototoxicity. 2

Treatment Options Based on Perforation Characteristics

For Small Perforations (≤3mm)

• Office-based patching with gelatin film or paper patch myringoplasty may be attempted first. 3
• Small perforations have a 46% chance of healing with office patching techniques. 4, 3
• This can be performed without anesthesia in an office setting. 4

For Larger Perforations (>5mm) or Expanding Perforations

• Surgical tympanoplasty is typically required, as spontaneous closure is unlikely. 4, 3
• Expanding perforations indicate active membrane retraction and will not heal without intervention. 1
• If initial office patching fails, adipose (fat patch) myringoplasty or formal tympanoplasty should be performed. 3

Success Rates

• First intervention (office patching or fat graft) succeeds in 91% of cases. 3
• For perforations requiring second intervention, 75% undergo formal tympanoplasty with excellent outcomes. 3

Critical Monitoring for Complications

Assess for Structural Changes

• The otolaryngologist must examine for retraction pockets, ossicular erosion, adhesive atelectasis, or cholesteatoma formation. 1
• Chronic perforations can develop these serious complications that require more extensive surgical intervention. 1
• Examination should be performed with an otomicroscope if there is any uncertainty about tympanic membrane structures. 1

Signs Requiring Immediate Attention

• Any ear drainage suggests infection and requires topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone drops). 2
• Never use aminoglycoside-containing drops (neomycin, gentamicin) as they cause severe permanent hearing loss through perforations. 2
• Worsening hearing, vertigo, or facial weakness requires emergency evaluation. 1, 5

Common Pitfalls to Avoid

Medication Errors

• Only use non-ototoxic fluoroquinolone ear drops if any topical treatment is needed. 2
• Avoid alcohol-containing drops, which are painful and ototoxic in the middle ear. 2
• Never irrigate the ear canal when perforation is present. 2

Delayed Referral

• Persistent perforations beyond 90 days after tube extrusion require specialist evaluation. 1
• The expanding nature of this perforation makes it a non-healing perforation that will not close spontaneously. 4, 3
• Delayed treatment increases risk of permanent hearing loss and structural complications. 1

Inadequate Follow-up

• Even after successful repair, periodic follow-up is essential to detect recurrence or complications. 1
• Children with history of chronic ear disease remain at risk for future tympanic membrane changes. 1