Can a perforated tympanic membrane become chronic and fail to heal?

Can Tympanic Membrane Perforations Fail to Heal?

Yes, tympanic membrane perforations can become chronic and fail to heal spontaneously, though most heal without intervention within 2-3 months. 1, 2

Natural History and Healing Rates

The majority of tympanic membrane perforations heal spontaneously, but failure rates exist:

• Most perforations (74-94%) heal spontaneously, with the majority closing within the first 3 months 2, 3
• Perforations persisting beyond 3 months are classified as chronic and typically require surgical intervention 4
• After tympanostomy tube extrusion, persistent perforation occurs in 1-2.6% of children, making it the most common sequela requiring intervention 5

Risk Factors for Non-Healing

Certain characteristics significantly predict failure of spontaneous closure:

• Large perforations (≥50% of tympanic membrane surface) have the poorest healing rates and often require surgery 2, 3
• Central kidney-shaped perforations demonstrate the least tendency to heal spontaneously 2
• Penetrating injuries through the ear canal are independent predictors of non-healing 3
• Middle ear infection or ear discharge significantly delays healing and increases failure risk 3, 6
• Pre-existing tympanosclerosis is the most prominent cause of healing failure 6
• Inappropriate interventions (ear syringing) significantly increase non-healing risk 3

Management Approach

Initial Conservative Management

For acute perforations, allow spontaneous healing with supportive care:

• Keep the ear dry to prevent infection 1, 7
• Avoid ear irrigation and pneumatic otoscopy when perforation is suspected or confirmed 1
• Use only non-ototoxic topical preparations if the tympanic membrane is not intact 5, 1, 7
• Reevaluate if symptoms persist beyond 2 weeks of treatment initiation 1

Timing for Surgical Intervention

Surgical intervention is recommended when the tympanic membrane remains unhealed for at least 10 months 2:

• Myringoplasty or tympanoplasty achieves 80-90% success rates for closure with a single outpatient procedure 5
• Growth factors (basic fibroblastic growth factor, epidermal growth factor) have demonstrated closure rates up to 98.1% when applied with appropriate scaffold materials after freshening perforation edges 1

Important Clinical Pitfalls

• Do not assume all perforations will heal: While most do, the risk factors above identify patients requiring closer surveillance 2, 3
• Avoid aggressive manipulation or irrigation: These interventions can enlarge perforations and delay healing 7, 3
• Monitor for squamous epithelial ingrowth: Persistent perforations can develop squamous epithelium growth through the perforation to the undersurface, requiring surgical excision 8
• Assess for structural changes: Chronic perforations may be associated with retraction pockets, ossicular erosion, or cholesteatoma development requiring intervention 5

Long-Term Outcomes

Even after successful closure (spontaneous or surgical):

• Mild hearing threshold worsening (1-2 dB) may occur but is not clinically significant 5, 1
• Children with history of tympanostomy tubes have 9.5-200 times greater risk of subsequent tympanoplasty compared to those without tubes or middle ear disease 5