What is the treatment approach for a patient with chronic tympanic membrane (TM) perforation, particularly one with a history of cholesteatoma or recurrent ear infections?

Treatment of Chronic Tympanic Membrane Perforation

For chronic TM perforation, surgical repair via tympanoplasty is the definitive treatment, with cartilage reconstruction providing superior structural outcomes compared to temporalis fascia, while medical management with topical non-ototoxic antibiotics serves only as a temporizing measure or for infection control. 1, 2

Initial Assessment and Medical Management

Diagnostic Evaluation

• Perform careful otoscopic examination to visualize the perforation and identify any whitish material suggesting cholesteatoma (appears as abnormal whitish material in the middle ear, often with TM retraction pockets). 1
• Obtain CT imaging to assess mastoid involvement and evaluate for potential intracranial complications, particularly when cholesteatoma is suspected. 1
• Conduct audiometric testing to document baseline hearing loss (perforations typically cause 25-decibel conductive hearing loss on average). 3

Medical Therapy

• Keep the ear dry to prevent infection—avoid irrigation and water exposure entirely. 2
• For active infection (chronic suppurative otitis media), use topical ofloxacin 0.3% otic solution: 10 drops (0.5 mL) instilled into the affected ear twice daily for 14 days in patients ≥12 years old. 4
• Never use ototoxic preparations (aminoglycosides, polymyxins) when the TM is not intact, as these cause permanent sensorineural hearing loss. 2
• Reserve systemic antibiotics for signs of invasive infection or mastoiditis with systemic symptoms, targeting S. pneumoniae, H. influenzae, and M. catarrhalis with amoxicillin or β-lactamase-stable agents. 2

Critical caveat: Medical management alone will not heal chronic perforations—it only controls infection temporarily. 5 Chronic suppurative otitis media is defined as chronic discharge through a TM perforation and requires surgery as definitive treatment. 3, 6

Surgical Management

Indications for Surgery

• All chronic perforations that persist beyond spontaneous healing period (most traumatic perforations heal within weeks). 5
• Immediate surgical indication for cholesteatoma—conservative "wait-and-see" strategies are inappropriate. 6
• High-risk perforations with recurrent infections despite medical management. 7
• Perforations causing significant hearing impairment requiring restoration. 7

Surgical Technique Selection

Use cartilage reconstruction (not temporalis fascia) for tympanoplasty, as it achieves superior structural outcomes with mean graft integration rate of 92.4% versus 84.3% for fascia, and significantly fewer postoperative perforations. 1, 7

Specific Technique Based on Pathology:

For cholesteatoma with intact malleus:

• Modified palisade cartilage technique for TM reconstruction. 7
• Complete cholesteatoma removal with mastoidectomy as needed. 1
• Recurrence rate of only 3.6% with this approach. 7

For high-risk perforation with intact ossicular chain:

• Perichondrium/cartilage island flap technique. 7
• Achieves 4.2% recurrent perforation rate. 7

For atelectatic ear or absent malleus:

• Perichondrium/cartilage island flap modification. 7
• Prevents retraction and failure seen with traditional techniques. 7

Novel Adjuvant Treatments

• Basic fibroblast growth factor (b-FGF) with gelatin sponge scaffold achieves 98.1% closure rate versus 10% with saline control—consider for difficult cases. 2
• Various bioengineered scaffolds are safe and improve healing rates. 2

Expected Outcomes

Hearing Results

• Cholesteatoma cases: Average postoperative air-bone gap improves from 26.5 dB to 14.6 dB. 7
• High-risk perforations: Average postoperative air-bone gap improves from 21.7 dB to 11.9 dB. 7
• Audiologic reconstruction cases: Average postoperative air-bone gap improves from 33.6 dB to 14.6 dB. 7

Complications

• Recurrent perforation: 1.0-4.2% depending on pathology. 7
• Conductive hearing loss requiring revision: 1.8-11% depending on indication. 7
• Cholesteatoma recurrence: 3.6% with appropriate cartilage technique. 7

Special Populations

For patients with diabetes or immunocompromised states:

• Require heightened vigilance due to increased complication risk. 1, 2
• Consider atraumatic cleaning with aural suctioning under microscopic guidance. 2
• More aggressive infection control may be necessary before surgery. 2

Follow-up Care

• Perform postoperative audiometric testing to assess hearing outcomes. 1
• Lifelong surveillance required for cholesteatoma cases due to recurrence risk. 6
• Monitor for late complications including myringosclerosis, atrophy, or persistent perforation. 3