What to do about a 30% eardrum perforation in a child that hasn't closed after tympanostomy tube removal?

Management of Persistent 30% Tympanic Membrane Perforation After Tympanostomy Tube Removal

This child requires prompt otolaryngology referral for surgical repair, as an enlarging perforation of this size 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 documented enlargement of the perforation from the original tube site. 1 The fact that this perforation has grown to 30% of the tympanic membrane and has not closed spontaneously indicates it will not heal without intervention. 1

Why This Won't Close on Its Own

• Perforations that persist and enlarge after tube removal, particularly those exceeding 20-25% of the tympanic membrane, have minimal chance of spontaneous closure 2
• The enlarging nature of this perforation is a critical red flag—it indicates ongoing structural compromise rather than a healing trajectory 1
• While some small perforations (under 10-15%) may close spontaneously within 6-12 months after tube removal, a 30% perforation that is actively enlarging will not 3, 2

Pre-Surgical Evaluation Needed

Before proceeding to surgery, the otolaryngologist must complete:

• Comprehensive audiometric testing to document the degree of conductive hearing loss, which is critical at this developmental age for speech and language development 1
• Assessment for active infection or otorrhea, as any active infection must be treated with antibiotic ear drops before surgical repair can proceed 1
• Evaluation of the contralateral ear to ensure no bilateral issues that might affect surgical planning 4

Surgical Repair: Timing and Approach

Surgery should occur within 3-6 months of confirming the perforation is persistent and enlarging. 1 Given that this perforation has already been observed over time and is documented to be enlarging, the child is likely ready for surgical intervention now.

Surgical Options

• Myringoplasty or tympanoplasty are the standard procedures with 80-90% success rates for closure in a single outpatient procedure 1
• The procedure is performed under general anesthesia and typically takes less than an hour 5
• Various graft materials can be used (temporalis fascia, tragal cartilage, or other materials), with the surgeon selecting based on perforation characteristics 2

Expected Outcomes

• Single-procedure success rate of 80-90% for complete perforation closure 1
• Hearing typically returns to normal after successful repair 1
• Risk of recurrent perforation after successful repair is low 1
• Most children recover quickly with minimal postoperative discomfort 2

Critical Developmental Considerations

At age 3.5 years, this child is in a critical period for speech and language development. 1 Even temporary conductive hearing loss from a 30% perforation can affect developmental milestones, making timely repair particularly important. 1 The conductive hearing loss from a perforation of this size is likely in the 15-30 dB range, which is sufficient to impact classroom learning and social interactions. 4

Common Pitfalls to Avoid

• Do not adopt a "wait and see" approach for a perforation that is documented to be enlarging—this is not a candidate for observation 1
• Do not delay referral hoping for spontaneous closure, as perforations of this size (30%) that are actively enlarging will not close without intervention 2
• Ensure the child avoids water exposure to the affected ear until surgical repair is completed, as water entry through the perforation increases infection risk 5

Risk Factors That Led to This Complication

This child's persistent perforation likely resulted from one or more known risk factors:

• Long tube retention time (2.5 years from age 1 to 3.5) is associated with higher perforation rates, particularly with T-tubes that were designed for long-term placement 6
• Young age at insertion (age 1) is associated with higher perforation rates 6
• Possible recurrent otorrhea while tubes were in place increases perforation risk 6

The reported incidence of persistent perforation after tympanostomy tube placement ranges from 3-14% in most series, with higher rates when tubes are retained longer than 2 years. 3, 6