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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 22  |  Issue : 2  |  Page : 100-104

Traumatic tympanic membrane perforation: An overview


1 Department of Otorhinolaryngology, SKIMS Medical College and Hospital, Srinagar, Jammu and Kashmir, India
2 Department of Pediatrics, SKIMS Medical College and Hospital, Srinagar, Jammu and Kashmir, India

Date of Web Publication11-May-2016

Correspondence Address:
Asef Wani
Department of Otorhinolaryngology, SKIMS Medical College and Hospital, Bemina, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.182276

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  Abstract 

Objectives: The purpose of this study was to determine the various etiologies of traumatic tympanic membrane (TM) perforations; their clinical presentation, observation and establish masterly inactivity as the main modality of management. Materials and Methods: A prospective study was performed on 350 cases of traumatic TM perforation in the Department of ENT, SKIMS Medical College, Srinagar from January 2010 to December 2014. Results: A total of 350 patients with the traumatic TM. Perforation was enrolled for this study. The group consisted of 231 male and 119 female patients. It affects all age groups with the highest incidence among middle age group. The right ear was involved in 94 (26.85%) patients, the left ear in 249 (71.14%) patients and bilateral ear involvement was seen in 7 (2%) patients. The type of trauma included compression injury in 243 (64.42%) patients, instrumental injury in 88 (25.14%) patients, and blast injury in 19 (5.42%) patients. Tinnitus was the most common complaint, followed by aural fullness, impaired hearing, otalgia, bleeding from ear and vertigo. 217 (62%) patients presented with conductive hearing loss in the range of 20–35 dB, 77 (22%) patients with <20 dB, 28 (8%) patients presented with >35 dB hearing loss, and 28 (8%) patients presented with no air-bone gap. Grade I perforation (<25% TM involvement) was seen in 91 (26%) patients, Grade II perforation (25–50% TM involvement) was seen in 221 (63.14%) patient, and Grade III perforation (>50% TM involvement) was present in 38 (10.90%) patients. Complete healing was observed within 2–6 weeks in 172 (49.10%) patients and within 7–9 weeks in 112 (32.20%) patients. 35 (10%) patients showed complete healing within 10–12 weeks. The minimum time taken to heal was 21 days and maximum time 72 days. Complete healing was observed in 319 (91.10%) patients. The intervention was only performed when spontaneous healing failed to occur after observing the patients for 1 week and included tympanoplasty in 8 (2.30%) patients, trichloroacetic acid cauterization in 14 (4%) patients. Residual perforation was observed in 9 (2.5%) patients. Conclusion: In our experience, traumatic TM perforation is still very common. Slap, instrumentation, road traffic accident, and blast injuries are common etiologies seen. It affects all age groups. Tinnitus and hearing loss are commonest symptoms. The masterly inactivity should be religiously followed and unnecessary surgical intervention should be discouraged.

Keywords: Hearing loss, Tinnitus, Traumatic perforation


How to cite this article:
Wani A, Rehman A, Lateef S, Malik R, Ahmed A, Ahmad W, Kirmani M. Traumatic tympanic membrane perforation: An overview. Indian J Otol 2016;22:100-4

How to cite this URL:
Wani A, Rehman A, Lateef S, Malik R, Ahmed A, Ahmad W, Kirmani M. Traumatic tympanic membrane perforation: An overview. Indian J Otol [serial online] 2016 [cited 2019 Nov 22];22:100-4. Available from: http://www.indianjotol.org/text.asp?2016/22/2/100/182276


  Introduction Top


The tympanic membrane (TM) is a thin wall that separates the outer ear from the middle ear.[1] It is much more traumatized than middle or inner ear.[2] The incidence has been estimated at 6.80/1000 persons.[3] The cause of acute rupture of TM include direct trauma by instruments such as cotton swab, pins and sticks, iatrogenic such as syringing, suction and probing of ear and skull fracture. Pressure changes include blast injury and open palm trauma (slapping), diving and flying.[4]

As expected the incidence of perforation of TM is on rise, consequent to increased violence and accidents seen in the present day life.[5] whether in war time or in peace time traumatic TM perforations have always been seen in otological trauma. Ritenour et al.[6] suggested that the mechanism of nonexplosive blast injury is similar to explosive blast injury. However various factors have proven to positively or negatively affect the individual susceptibility to TM rupture. The factors which include previous disease or injury, increased age, inadequate pneumatization and TM position perpendicular to incident wave, increase the likelihood of perforation.

The symptoms of traumatic TM perforation include impaired hearing, aural fullness, tinnitus, otalgia and in severe cases there may be bleeding from ear and vertigo.

Most studies suggest that upward of 90% of traumatic perforations heal spontaneously within 3 months of injury.[3] The patient besides symptomatic treatment need proper counseling and psychological support. Masterly inactivity should be religiously followed as spontaneous healing is achieved in more than 90% patients over a period of 2–14 weeks. People and health care professionals need to be educated and unskilled attempts at removal of wax and foreign bodies from external auditory canal need to be discouraged.


  Materials and Methods Top


The study was undertaken in the ENT Department of SKIMS Medical College and Hospital, Bemina, Srinagar, a tertiary care teaching hospital. The patients with a history of trauma (assault, pin prick, syringing, iatrogenic etc.) sustained not earlier than 2 weeks and with absolutely no previous history of any ear disease were included in the study. A detailed clinical and otoscopic examination was performed and associated symptoms such as vertigo and tinnitus were noted. Tuning fork test, and pure tone audiometry (PTA) was performed on all patients. Follow-up visits were scheduled at 1 week, 2 weeks, 4 weeks, 8 weeks, and 10 weeks and further follow-up was tailored to the needs of the individual patient. The PTA was repeated on 2nd and 4th visit. The data retrieved included the following parameters: sex, age and side, cause of injury and symptoms such as earache, hearing loss, tinnitus, and vertigo were recorded. The eardrum appearance was assessed by otoscope/microscope. The following criteria were used to estimate the relative size of the perforations: small perforation, less than one-fourth of the TM, medium perforation less than one-half of the TM and large perforation, more than one-half of the TM. PTAs were determined for air and bone conductions at 500, 1000, 2000, and 4000 Hz. A conservative management approach was adopted, except for those with bloody or watery discharge who received oral/systemic antibiotics to prevent infection. The patients were advised not to wet the ears and to antedate their appointments if discharge appeared. The assessment of follow-up visits was recorded at least 3 times for every patient.


  Results Top


A total of 350 patients with traumatic TM perforation were enrolled in the study. The group consisted of 231 males and 119 females.

Age distribution

The age ranged from 5 to 69 years. In this series, 238 (68%) of the patients were in the age group of 21–40 years. The youngest patient was a 5 years old who sustained traumatic perforation of the right TM as a result of slap injury. The oldest patient was a 69-year-old man [Table 1].
Table 1: Different age - group of patients with percentage

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Laterality

The right ear was involved in 94 (26.85%) patients, the left ear in 249 (71.14%) of patients, and bilateral ears in 7 (2%) patients [Table 2].
Table 2: Percentage of unilateral/bilateral tympanic membrane rupture

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Etiology

In our study, the most common etiology of traumatic perforation of TM was injury caused due to physical assault (69.42%). Iatrogenic, i.e., during removal of foreign body accounted for 13.42% of cases, syringing accounted for 11.7% of cases and blast injury leading to rupture of TM was rare and contributed to 5.4% of cases [Table 3].
Table 3: Various etiologies of tympanic membrane rupture

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Presenting complaints

In our study, tinnitus was the most common complaint (90.9%), the next common complaint was aural fullness (87.1%) followed by reduced hearing (58.6%), aural pain (30%), bleeding from ear (6.3%), and vertigo (1.4%) [Table 4].
Table 4: Clinical presentation of patients with percentage

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Size of perforation

In our study, of the 350 patients, 91 (26%) patients had Grade I perforation involving <25% of the TM, 221 (63.1%) patients had larger Grade II perforations involving 25–50% of the eardrum, 38 (10.9%) patients had Grade III perforation involving more than 50% of the TM [Table 5].
Table 5: Grading of tympanic membrane perforation

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Hearing loss

In our study, majority of patients (62%), presented with conductive hearing loss in the range of 20–35 dB, 22% of patients with <20 dB, and only 8% of patients presented with >35 dB hearing loss. While 8% of the patients had no air-bone gap [Table 6].
Table 6: Air-bone gap among patients with percentage

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Number of perforation

In our study, 323 (92.3%) patients had single perforation and 27 (7.7%) had multiple perforations [Table 7].
Table 7: Number of perforations

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Healing time

In our study, 172 (49.1%) patients had spontaneous healing within 2–6 weeks, 112 (32.2%) patients within 7–9 weeks and 35 (9.8%) patients within 10–12 weeks. The shortest time taken was 21 days and the longest was 72 days [Table 8].
Table 8: Healing time among patients

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Outcome

In our study, the overall spontaneous healing was achieved in 91.1% of patients. Tympanoplasty was done in 8 (2.3%) of patients, trichloroacetic acid cautery in 14 (4%) patients and residual perforation was found in only 9 (2.5%) patients [Table 9].
Table 9: Overall recovery among patients

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  Discussion Top


The TM is an important component of sound conduction as its vibratory characteristic is necessary for sound transmission in human beings.[7] Trauma to TM can be caused by over pressure, blunt or penetrating injuries and barotraumas.[8],[9] In our study, over pressure was the most common cause of trauma to TM similar to various studies elsewhere.[8],[9],[10]

Traumatic TM perforations are seen in all age groups. In our study, middle age group (20–40 years) has the highest incidence similar to studies undertaken by Gacek and Gacek [7] and Berger et al.[11] Male to female involvement was 1.94:1.00. This result is not in accordance with various studies. Lindeman et al.[12] reported greater prevalence among females similar to study reported by Lou et al.[13] However, a higher male involvement was reported by Gacek and Gacek [7] and da Lilly-Tariah and Somefun [9] The higher prevalence among males, in our study, can also be explained by the fact that study was undertaken in a conflict zone.

In our study, 98% of patients had unilateral involvement. The right ear involvement was seen in 26.85% of patients and left ear was involved in 71.10% patients. This could be associated with the fact that most assailants were right handed and likely that most of the acts of trauma such as slap occurred with the assailant and the victim facing each other making the left ear more vulnerable to trauma. Lindeman et al.[12] and Berger et al.[11] reported a similar predilection for left ear. Attempts at removal of foreign bodies from external auditory canal, self-ear cleaning with a variety of objects and wax removal in an unskilled manner either by parents, quacks or primary care physician are other important causes of trauma as are also reported in various other studies.[10],[14],[15],[16] Thus, there is a need for the primary care physician to draw the red lines and routinely consider the referral in all such cases.

In our study regardless of mechanism of injury, tinnitus was the most common complaint (90.90%). The next common complaint was aural fullness (87.10%), followed by reduced hearing (56.60%), aural pain (30%), bleeding from ear (6.30%), and vertigo (1.40%). In the study by Berger et al.[11] and da Lilly-Tariah and Somefun [9] hearing loss followed by tinnitus and otalgia were common complaints. In our study, hearing loss increased with increase in size of perforation at each frequency. It is due to hydraulic action arising from the difference in area of foot plate, the most important factor in impedance matching.[16] When the surface area is decreased, there is decrease in amplification and hearing loss will be proportional to the size of perforation.[17]

Most traumatic perforation have a tendency to heal spontaneously, there was 91.80% healing in our study similar to other studies.[18],[19],[20],[21],[22]

Residual perforation was observed only in 2.50% patients. The data strongly suggests that prolonged observation remains an excellent option for patients presenting with traumatic TM perforation.

Traumatic perforations often occur in community and generally the prognosis is excellent.[23] The two main factors that predispose to failure of perforation to heal area, loss of tissue, and secondary infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Culvert L, Turkington, Carol. Perforated Eardrum. Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved February 17, 2016 from Encyclopedia.com:http://www.encyclopedia.com/doc/1G2-3447200432.html.  Back to cited text no. 1
    
2.
Quinn FB Jr., Ryan MW, Quinn MS, Steven T, Wright MD, Shawn Newlands, et al. Trauma to the Middle and Inner Ear October 23, 2002. Grand Round Presentation UTMB, Department of Otolaryngology; 2002.  Back to cited text no. 2
    
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Griffin WL Jr. A retrospective study of traumatic tympanic membrane perforations in a clinical practice. Laryngoscope 1979;89 (2 Pt 1):261-82.  Back to cited text no. 3
    
4.
Ott MC, Lundy LB. Tympanic membrane perforation in adults. How to manage, when to refer. Postgrad Med 2001;110:81-4.  Back to cited text no. 4
    
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Peter JK, Paul HK. Principle of trauma In Byron J Bailey Head and Neck Surgery - Otolaryngology. (3rd edn), Lippincott Williams and Wilkins Publishers; 2001.  Back to cited text no. 5
    
6.
Ritenour AE, Wickley A, Ritenour JS, Kriete BR, Blackbourne LH, Holcomb JB, et al. Tympanic membrane perforation and hearing loss from blast overpressure in operation enduring freedom and operation Iraqi freedom wounded. J Trauma 2008;64 2 Suppl:S174-8.  Back to cited text no. 6
    
7.
Gacek RR, Gacek MR. Anatomy of the auditory and vestibular systems. In: Snow JB Jr., Ballenger JJ, editors. Ballenger's Otorhinolaryngology Head and Neck Surgery. 16th ed., Vol. 1. Ontario: DC Becker Inc.; 2003. p. 1-5.  Back to cited text no. 7
    
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Mitchell KS, MD. Trauma to the Middle Ear, Inner Ear, and Temporal Bone. Ballenger's Otorhinolaryngology Head and Neck Surgery. 16th ed. Chapter 14. 2003. p. 345-56. (Edition James B. Snow Jr, MD Professor Emeritus University of Pennsylvania Philadelphia, Maryland John Jacob Ballenger, MD Associate Professor Department of Otolaryngology–Head and Neck Surgery Northwestern University Chicago, Illinois Chief Emeritus Division of Otolaryngology–Head and Neck Surgery Evanston Hospital Evanston, Illinois).  Back to cited text no. 8
    
9.
da Lilly-Tariah OB, Somefun AO. Traumatic perforation of the tympanic membrane in University of Port Harcourt Teaching Hospital, Port Harcourt. Nigeria. Niger Postgrad Med J 2007;14:121-4.  Back to cited text no. 9
    
10.
Ologe FE. Traumatic perforation of tympanic membrane in Ilorin Nigeria. Niger J Surg 2002;8:9-12.  Back to cited text no. 10
    
11.
Berger G, Finkelstein Y, Harell M. Non-explosive blast injury of the ear. J Laryngol Otol 1994;108:395-8.  Back to cited text no. 11
    
12.
Lindeman P, Edström S, Granström G, Jacobsson S, von Sydow C, Westin T, et al. Acute traumatic tympanic membrane perforations. Cover or observe? Arch Otolaryngol Head Neck Surg 1987;113:1285-7.  Back to cited text no. 12
    
13.
Lou ZC, Lou ZH, Zhang QP. Traumatic tympanic membrane perforations: A study of etiology and factors affecting outcome. Am J Otolaryngol 2012;33:549-55.  Back to cited text no. 13
    
14.
Ladapo AA. Danger of foreign body in the ear. Niger Med J 1979;9:120-2.  Back to cited text no. 14
    
15.
Ijaduola GT, Okeowo PA. Foreign body in the ear and its importance: The Nigerian experience. J Trop Pediatr 1986;32:4-6.  Back to cited text no. 15
    
16.
Ahmad SW, Ramani GV. Hearing loss in perforations of the tympanic membrane. J Laryngol Otol 1979;93:1091-8.  Back to cited text no. 16
    
17.
Chun SH, Lee DW, Shin JK. A Clinical Study of Traumatic Perforation of Tympanic Membrane. Seoul, Korea: Department of O tolaryngology, Hanil General Hospital 2010;113:679-86.  Back to cited text no. 17
    
18.
Orji FT. Non-explosive blast injury of the ear. J Laryngol Otol 1994;108:395-8.  Back to cited text no. 18
    
19.
Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforations of the tympanic membrane. Clin Otolaryngol 2008;33:420-6.  Back to cited text no. 19
    
20.
Kristensen S, Juul A, Gammelgaard NP, Rasmussen OR. Traumatic tympanic membrane perforations: Complications and management. Ear Nose Throat J 1989;68:503-16.  Back to cited text no. 20
    
21.
Yamazaki K, Ishijima K, Sato H. A clinical study of traumatic tympanic membrane perforation. Nihon Jibiinkoka Gakkai Kaiho 2010;113:679-86.  Back to cited text no. 21
    
22.
Ijaduola GT. The principles of management of deafness. Niger Med J 1986;12:19-25.  Back to cited text no. 22
    
23.
Toner JG, Kerr AG. In Scott-Brown's Otolaryngology. Butterworths Meinemann, London: Otology. 6th ed. Edited by: Booth JB, Kerr, Advisory AG, Groves J. Ear Trauma 1997;3:1-3.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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