Basics
Description
Perforations can be classified in several ways:
- Duration:
- Acute (<3 mo)
- Chronic (>3 mo)
- Site:
- Extent:
- Limited to 1 quadrant (<25%)
- 2 or more quadrants
- Total perforation
Etiology
- Infection (acute otitis media):
- Most common cause of an acute perforation
- Blunt trauma (slap to the ear):
- Domestic violence, street fight
- Penetrating trauma (Q-tip)
- Extrusion of tympanostomy tubes
- Rapid pressure change (diving, flying):
- Rupture usually occurs between 100 and 400 mm Hg (at a depth of 2.6 ft, there is a pressure differential of 60 mm Hg)
- Extreme noise (blast)
- Lightning
- Acute necrotic myringitis ( ²-hemolytic streptococcus)
- Slag burns (welding or metalworking)
- Complications of surgical procedures:
- Myringotomy, tympanoplasty, tympanostomy tube insertion
Diagnosis
Signs and Symptoms
History
- Ear pain (mild)
- Severe pain or complete hearing loss in the affected ear suggests additional injuries
- Tinnitus
- Vertigo (especially if perforation occurs in water)
Physical Exam
- Loss of hearing (partial)
- Purulent or bloody discharge from ear canal
- Insufflation via pneumatic otoscope:
- Small perforations may be evident only as an immobile tympanic membrane
- Holding pressure for 15 sec (the fistula test) may cause nystagmus or vertigo if the pressure is transmitted through the middle ear and into a labyrinthine fistula
- Weber test (tuning fork on midline bone):
- Sound should be equal or louder in the injured ear, consistent with decreased conduction
- Sound localizing to the opposite side of injury indicates possible otic nerve injury
- Rinne test (tuning fork on mastoid process):
- Usually normal (air conduction detected after bone conduction fades) or shows a small conductive loss
Essential Workup
Clinical exam:
- Direct visualization of tympanic membrane with otoscope
- Test hearing in both ears
- Note any nystagmus with changes of position or pressure on the tragus occluding the canal (fistula sign)
Diagnosis Tests & Interpretation
Lab
If an aural drainage is present, it may be desirable to culture the drainage
Imaging
Cranial CT:
- Obtain if clinically indicated to rule out temporal bone fracture
Differential Diagnosis
- Temporal bone fracture
- Serous otitis media
- Infectious otitis media
- Otitis externa
- Cerumen impaction
- Barotrauma
- Acoustic trauma
- Foreign body
- Child abuse
Treatment
Initial Stabilization/Therapy
ABCs of trauma care:
- Immobilize cervical spine and investigate for intracranial injury when indicated
Ed Treatment/Procedures
- Remove debris from the ear canal:
- Do not irrigate because this may force more debris into the middle ear
- If the tympanic membrane is not visible because of impacted cerumen and suspicion for perforation is high, remove cerumen by manual disimpaction or suctioning
- If clinically indicated, obtain CT scan to rule out temporal bone fracture
- Prophylactic antibiotics are not indicated
- Prescribe antibiotics if there is evidence of infection or if water or contaminants may have entered the ear canal:
- Amoxicillin
- Augmentin
- Cefixime, ceftriaxone
- Azithromycin
- Clindamycin
- Analgesics if needed for pain
- With the exception of fluoroquinolones, the use of ototopical medication is controversial because of the risk of ototoxicity:
- Most advocate an antibiotic " cortisone otic medication whenever a discharge is present because this may treat or prevent an external canal infection and hasten the resolution of the middle-ear infection
- Ototopical antibiotics provide a high concentration of antibiotic in the middle ear, potentially exceeding the MIC of organisms
- Ototopical fluoroquinolones are the 1st-line therapy for chronic suppurative otitis media and in traumatic TM perforation with suspected entry of water into the middle ear (SCUBA, bathing, etc.)
- Urgent ENT consultation (indications):
- Vertigo
- Sensorineural hearing loss
- Severe tinnitus
- Active and significant bleeding
- Facial paralysis
Medication
- Amoxicillin: 500 mg PO TID (peds: 80 " 90 mg/kg/24 h PO BID) for 7 " 10 days
- Augmentin: 875 mg (peds: 90 mg/kg/24 h) PO BID for 7 " 10 days
- Cefixime: 400 mg (peds: 8 mg/kg/24 h) PO QD for 7 " 10 days
- Ceftriaxone: 1 " 2 g IV/IM (peds: 50 mg/kg IM, max. 1 g) 1 dose
- Azithromycin: 2 g (peds: 30 mg/kg, max. 1,500 mg) PO 1 dose
- Clindamycin: 150 " 450 mg (peds: 30 mg/kg/24 h) PO QID for 7 " 10 days
- Ciprofloxacin/dexamethasone otic: 4 drops BID for 7 " 10 days
- Neomycin/polymyxin B/hydrocortisone otic suspension: 4 gtts in ear TID " QID (peds: 3 gtts TID " QID); max. 10 days; lie with affected ear upward for 5 min
First Line
- Amoxicillin and Augmentin are the primary antibiotic choices for acute otitis media with subsequent tympanic membrane perforation
- Augmentin should be selected for patients with recurrent infections or those who have used antibiotics within 1 mo
- Ciprofloxacin with dexamethasone otic drops are the medications of choice for chronic suppurative otitis media and traumatic tympanic membrane perforation with suspicion of water or contaminant entry into the middle ear (SCUBA, bathing, Q-tip)
Second Line
- Penicillin-allergic patients may be prescribed cephalosporins:
- Ceftriaxone IM may be preferred in patients with vomiting or compliance issues
- Azithromycin or clindamycin may be used for patients with hypersensitivity type I allergic reaction to penicillin
Follow-Up
Disposition
Admission Criteria
- Associated injuries requiring admission
- Severe vertigo impairing ambulation
Discharge Criteria
Almost all patients will be discharged
Issues for Referral
- Arrange outpatient ENT follow-up within 1 wk:
- After detailed exam and formal audiometric tests, most otolaryngologists practice "watchful waiting " because most tympanic membrane perforations heal spontaneously
- Hearing loss increases with the size of the perforation and does vary appreciably with the location
- Operative repair (patch or tympanoplasty) is reserved for the 10 " 20% that do not heal spontaneously
Follow-Up Recommendations
- Provide detailed discharge instructions:
- Occlude the ear canal with cotton coated in petroleum jelly or antibiotic ointment when showering to prevent entry of water into the middle ear, which can be painful and may cause further infection
- Swim only with fitted earplugs
- Avoid forceful blowing of the nose
- Expected outcome:
- Most perforations heal spontaneously in a few days to several months; in 1 study of children, 70% closed within 1 wk and 94% closed within 1 mo
- Spontaneous healing is associated with the perforation size, etiology, and whether it is dry or serosanguinous
- Wet perforations tend to heal more quickly
- Perforations caused by molten metal or electrical burns are less likely to heal spontaneously
- Complications include:
- Infection
- Dislocation of ossicles
- Perilymph leak
- Cholesteatoma
Pearls and Pitfalls
- Acute otitis media is the most common cause of tympanic membrane perforation.
- Small tympanic membrane perforations may be diagnosed only through insufflation by pneumatic otoscope
- Debris, cerumen, or discharge should be suctioned or manually removed; irrigation is contraindicated in cases of suspected tympanic membrane perforation
- Ototopical fluoroquinolones are the antibiotics of choice for chronic suppurative otitis media and traumatic tympanic membrane perforation with suspected penetration by foreign body, water, or contaminant
- Most perforations heal spontaneously; however, care must be exercised to prevent further introduction of infectious agents into the open middle ear
- Chronic otitis media is a recurrent infection of the middle ear and/or mastoid air cell tract in the presence of a tympanic membrane perforation
- Chronic suppurative otitis media is diagnosed when there is a persistent purulent drainage through a perforated tympanic membrane for >6 wk
- Use neomycin/polymyxin B/hydrocortisone otic SUSPENSION (not solution) when treating otitis externa in the setting of TM perforation
Additional Reading
- Lou ZC, Tang YM, Yang J. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin Otolaryngol. 2011;36:450 " 460.
- Macfadyen CA, Acuin JM, Gamble C. Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations. Cochrane Database Syst Rev. 2006;(1):CD005608.
- Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007;76:1650 " 1658.
- Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009;79:650, 654.
See Also (Topic, Algorithm, Electronic Media Element)
Codes
ICD9
- 384.20 Perforation of tympanic membrane, unspecified
- 384.22 Attic perforation of tympanic membrane
- 872.61 Open wound of ear drum, without mention of complication
- 382.01 Acute suppurative otitis media with spontaneous rupture of eardrum
- 384.00 Acute myringitis, unspecified
ICD10
- H72.10 Attic perforation of tympanic membrane, unspecified ear
- H72.90 Unsp perforation of tympanic membrane, unspecified ear
- S09.20XA Traumatic rupture of unspecified ear drum, initial encounter
- H66.019 Acute suppr otitis media w spon rupt ear drum, unsp ear
- H73.009 Acute myringitis, unspecified ear
SNOMED
- 60442001 Perforation of tympanic membrane (disorder)
- 307497002 Traumatic tympanic membrane perforation
- 194315002 Tympanic membrane attic perforation (disorder)
- 86279000 Acute suppurative otitis media with spontaneous rupture of ear drum
- 297009 Acute myringitis (disorder)