What are the signs and symptoms of a ruptured eardrum (tympanic membrane perforation), particularly in children and young adults with a history of recurrent ear infections?

Signs and Symptoms of a Ruptured Eardrum

A ruptured tympanic membrane typically presents with sudden hearing loss (95% of cases), ear pain, and often visible bleeding from the ear canal, though symptoms can be surprisingly subtle or even absent in some patients. 1, 2

Primary Clinical Manifestations

Acute Symptoms at Time of Rupture

• Sudden hearing loss is the most consistent finding, occurring in approximately 95% of traumatic perforations 2
• Ear pain (otalgia) - though notably, this may be mild or absent despite perforation 1
• Bleeding from the ear canal - blood appearing in the external auditory canal is a common presenting sign 3, 2
• Aural fullness - sensation of pressure or blockage in the affected ear 1
• Mild tinnitus - ringing or buzzing sounds 1

Associated Symptoms Suggesting Complications

• Vertigo, nausea, and vomiting - these symptoms suggest possible disruption of the ossicular chain or inner ear involvement and warrant urgent otolaryngologic evaluation 1, 4
• Severe or profound hearing loss (>30 dB conductive loss) - indicates potential ossicular chain disruption 1
• Profound sensorineural hearing loss - may signify inner ear nerve damage requiring immediate specialist referral 1, 4
• Persistent or worsening vestibular symptoms - suggest perilymphatic fistula 4

Context-Specific Presentations

In Acute Otitis Media (AOM)

When perforation occurs as a complication of AOM, patients typically have preceding symptoms of middle ear infection 5:

• Acute ear pain that may suddenly improve when perforation occurs and pressure is released 5
• Purulent discharge (otorrhea) draining through the perforation 5, 4
• Fever and systemic illness in the context of the underlying infection 5

In Children and Young Adults with Recurrent Infections

• Ear manipulation in preverbal children (tugging, rubbing, or holding the ear) 5
• Excessive crying or changes in sleep and behavior patterns 5
• Hearing difficulties that may manifest as inattention, poor school performance, or language delays 5
• Recurrent episodes of ear pain and discharge if chronic suppurative otitis media develops 5

Important Clinical Pitfalls

Subtle or Absent Presentations

Many perforations can be asymptomatic or have minimal symptoms, particularly small perforations 1, 3. One case report documented an intrapartum tympanic membrane rupture that was completely asymptomatic until blood appeared in the ear canal 3. This underscores that absence of pain does not exclude perforation.

Distinguishing from Other Conditions

• Do not confuse with tympanic membrane retraction: A retracted membrane indicates eustachian tube dysfunction and negative middle ear pressure, not perforation or active infection 6
• Bulging versus perforation: In AOM without perforation, the tympanic membrane is bulging, reddened, and opaque; after perforation, these findings may resolve as pressure is released 6

Physical Examination Findings

On otoscopic examination, clinicians should look for 1, 4:

• Visible perforation in the tympanic membrane
• Blood, purulent secretions, or debris in the ear canal that should be carefully suctioned for adequate visualization 1, 4
• Perforation size and location should be documented 1
• Avoid irrigation and pneumatic otoscopy when perforation is suspected, as these can cause caloric effects, vertigo, or introduce infection into the middle ear 1

Hearing Assessment

• Conductive hearing loss is typical with most perforations, usually mild (<30 dB) 1
• Conductive loss >30 dB suggests ossicular chain disruption requiring specialist evaluation 1
• Sensorineural hearing loss indicates inner ear damage and requires urgent referral 1, 4