Management of Persistent and Enlarging Tympanic Membrane Perforation After Tympanostomy Tube Removal
This child requires prompt otolaryngology referral for surgical repair, as an enlarging perforation after tube removal will not close spontaneously and risks progressive hearing loss and chronic infection. 1
Immediate Action Required
- Schedule otolaryngology evaluation within 2-4 weeks given the progressive enlargement of the perforation. 1
- The perforation is enlarging rather than healing, which indicates it will not resolve with observation alone and requires surgical intervention. 1
- Delaying repair risks further enlargement, increased conductive hearing loss, and potential for chronic ear infections. 1
Pre-Surgical Assessment
Before surgical repair, the following evaluations are essential:
- Audiometric testing must be performed to document the current degree of conductive hearing loss and establish baseline hearing status. 1
- Examination for active infection or ear drainage is critical, as any active infection must be treated with topical antibiotic drops before proceeding with surgical repair. 1
- At age 3.5 years, even temporary hearing loss from the perforation can significantly impact speech and language development, making timely repair particularly important. 1
Surgical Timing and Approach
- Surgery should occur within 3-6 months of confirming the perforation is persistent and enlarging. 1
- The standard procedures are myringoplasty or tympanoplasty, both performed as outpatient surgery. 1
- These procedures have 80-90% success rates for perforation closure with a single operation. 1, 2
- After successful repair, hearing typically returns to normal, and the risk of recurrent perforation is low. 1
Why This Perforation Won't Heal Spontaneously
The clinical scenario described—a retained tube requiring manual removal followed by an enlarging rather than healing perforation—indicates unfavorable healing characteristics:
- Long-term tube retention (the tube stayed in place from age 1 to 3.5 years, approximately 30 months) significantly increases the risk of persistent perforation after removal. 3, 2
- Short-term tubes typically stay in place 8-18 months, while this tube remained much longer, creating a larger and less favorable perforation. 3
- The fact that the perforation is actively enlarging rather than contracting confirms it will not heal without surgical intervention. 1
Common Pitfalls to Avoid
- Do not adopt a "wait and see" approach when a perforation is documented to be enlarging, as spontaneous closure becomes progressively less likely with time and increasing size. 1
- Do not delay audiometric testing, as unrecognized hearing loss at this critical age for language development can have lasting consequences. 1
- Avoid operating through active infection; any ear drainage must be treated first with topical antibiotics. 1