Perforation

Aetiology

• Trauma
• Infection
  • Otitis Media
  • Acute Chronic Otitis Media
  • Most acute tympanic membrane perforations from infection spontaneously resolve with treatment of the infection
  • Occasionally, when the infections are frequent, there is extensive scarring (tympanosclerosis) of the eardrum and middle ear 
  • This compromises the blood supply to the healing eardrum and, occasionally, stops the hole from healing. 
  • These patients often have discharging ears when there is water exposure or with upper respiratory tract infections
• Middle Ear Barotrauma (e.g. Scuba Injury) – large or rapid changes in pressure gradients between the middle and external ear
• Physical abuse red flag
• Foreign body
• Forceful Ear Irrigation

Symptoms

• sudden onset of pain
• followed by relief
• with associated otorrhea
• Tinnitus and vertiginous symptoms may also be experienced

Red flags

• Marginal perforations
• Attic perforations
• Chronically discharging or bleeding ear
• Perforation with significant clinical hearing loss 

Signs

• Otoscope fogging may also be used as an indicator for perforation
• pneumatic otoscopy should generally be avoided for the risk of damage to the middle ear
• Traumatic perforations often lack discharge
• Weber lateralizes to side of perforation
• location of the perforation in the eardrum is clinically relevant.
• Unsafe vs Safe perforation
  • Safe:
    • a hole in the tympanic membrane
    • dry and central
    • away from the attic or the annulus margins
    • These will generally not progress to serious pathology.
  • Unsafe:
    • Marginal Perforations:
      • Definition: Perforation reaching the annulus of the eardrum.
      • Risk: Disrupts the normal epithelial flow from the tympanic membrane to the external auditory canal, potentially leading to cholesteatoma.
    • Attic Perforations:
      • Definition: Perforation above the short process of the malleus.
      • Risk: Similar to marginal perforations, may disturb normal epithelial flow and indicate cholesteatoma.
    • Cholesteatoma
      • Not actual holes in the eardrum
      • represent retraction of the tympanic membrane.
      • Eardrum is pulled inward.
      • Retraction can gradually enlarge.
      • Skin debris accumulates in the retracted area.
      • Accumulated debris may become infected.
      • Leads to the development of cholesteatoma.
      • Cholesteatoma can erode bone.
      • Can cause serious, potentially life-threatening complications.
      • Hence, considered unsafe.

• 

Management

Keep ear dry

• No swimming
• Ear plugs (or cotton balls in vaseline) for showering or bathing

ENT Consultation indications

• Most cases of TM Perforation
• Unsafe perforations 
• Possible ossicle disruption
• Associated Vertigo (may be due to inner ear injury, consult within 24 hours)
• Surgery may be required if
  • perforations are located in the posterosuperior quadrant
  • caused by penetrating trauma
  • has been present for less than two months
  • (are associated with poor routine healing)

Acute Traumatic Perforations:

• Treatment: Typically heal spontaneously.
• Antibiotics: Used if the middle ear is soiled (e.g., amoxicillin for a week).
• Water Precautions: Patients should avoid water exposure and be regularly checked until the perforation heals, usually within a few weeks.

Chronic Perforations:

• Definition: Perforations that do not heal spontaneously.
• Dry Safe Central Perforations:
  • Asymptomatic: Generally left alone.
  • Symptomatic: Managed surgically with tympanoplasty to repair the eardrum and/or ear bones.

Unsafe Perforations:

• Surgical Management: Necessary to treat or prevent cholesteatoma.
• Surgical Techniques:
  • Conservative: Intact canal wall mastoidectomy or atticotomy.
  • Radical: Modified radical or radical mastoidectomy.
• Goals:
  • Remove disease.
  • Create a safe, dry ear.
  • Secondary goal of restoring hearing.

Antibiotics:

• Usually heal spontaneously with appropriate culture-directed antibiotic treatment.
• indications
  • Acute Perforations from Infection
  • Concurrent Otitis Media
  • TM Perforation in a wet, contaminated environment such as seawater (and also keep canal dry)

• Topical, non-ototoxic antibiotic options
  • 100x oral concentration (may also add oral aminopenicillin antibiotics)
• Combinations with steroid result in faster resolution but are much more expensive
  • Ofloxacin 0.3% (Floxin Otic) 5 drops (10 drops if over age 12) twice daily for 7 days
  • Ciprofloxacin ophthalmic (ciloxan drops) 4 drops twice daily for 7 days
  • Ciprofloxacin 0.3% with Dexamethasone 0.1% (Ciprodex) 4 drops in ear twice daily for 7-10 days
  • Ciprofloxacin 0.3% with Fluocinolone Acetonide 0.025% (Otovel) 0.25 ml vial in ear twice daily for 7 days
• Ototoxic
  • Any antibiotic ear drops that has framycetin (an aminoglycoside)

Surgical Indications

• Most Cases of Tympanic Membrane Perforation.
• Unsafe Perforations.
• Possible Ossicle Disruption.
• Associated Vertigo: Indicative of possible inner ear injury, requiring consultation within 24 hours.
• Persistent or Poor Healing Perforations:
  • Located in the posterosuperior quadrant.
  • Caused by penetrating trauma.

Prognosis

• Usually heal well spontaneously (95% of cases) in 4-6 weeks
• Large or marginal perforations may require surgery

Key Takeaways

• Examination: Includes both anatomical and physiological assessments.
• Diagnosis: Based on visual inspection and relevant symptoms.
• Management: Tailored to the type and severity of perforation, with a focus on preventing complications like cholesteatoma.
• Patient Education: Importance of water precautions and regular follow-up.
• Referral: Timely ENT consultation for complex or non-healing cases.