Eardrum Perforation: Causes, Symptoms and Treatment

The purpose of the eardrum or tympanic membrane (TM) is to transmit sound vibrations through the small bones behind the TM called the ossicular chain to the cochlea or inner ear. The TM and the ossicles function as transducers, converting sound energy into electrical energy. A hole in the eardrum can be a result of various causes.

The eardrum or tympanic membrane (TM) is a fascinating structure. It can be stiff in one portion, but flexible in another, translucent or opaque. It has different layers and different functional areas or zones. The larger of the two zones is tougher and more resilient than the smaller one.

A rupture of the TM is a diagnosis made clinically. In many cases, nothing needs to be done other than treating an underlying condition such as an infection, if that is the issue. In other cases, repair is necessary.

The leading cause of a TM perforation is infection, the next category of causes is trauma. Let us deal with each separately.

The leading cause - acute infection of the middle ear

Acute infection of the middle ear, or the area behind the TM, causes changes in pressure behind the drum.

For the TM to be functional, the air pressure in front and behind the drum must be the same. We have a relief valve of sorts called the eustachian tube that continually adjusts the pressure gradient, making sure the TM is stable. The eustachian tube has two openings, one in the back of our throat and the other in the middle ear.

Acute infection causes relative ischemia of the TM, or lack of oxygen and nutrients, because the middle ear pressure is increased. The eustachian tube cannot release the pressure so the only way out is through the TM, and it bursts. A TM rupture is usually preceded by severe pain. The TM perforation may be temporary or permanent.

Treatment is focused on solving the infection first. Today, fewer antibiotics are being used because of the prevalence of viral infections and antibiotic-resistant bacterial strains. Unfortunately, these trends are leading to progression of more severe infections involving more severe consequences.

Ironically, the TM perforation helps, not hinders, the treatment of the infection by allowing for pressure equalization. We are all familiar with the placement of ear tubes, particularly in children, but some adults get them too. PE (pressure equalization) tubes or a purposeful TM perforation are necessary to treat the infections. Most of these TM perforations, even from PE tubes, heal spontaneously as long as the infection subsides. Roughly 1% of those patients with chronic eustachian tube dysfunction or infection may develop a chronic perforation. Interestingly, in many of these patients the presence of a dry, longstanding hole in the eardrum may be preventive of further problems, leaving the person with little or no appreciable hearing loss.

Traumatic perforations

Traumatic perforations may result from a myriad of causes.

• Blows to the ear (being struck by an open hand or falling into a pool or lake and hitting the water surface causing a “slap” injury or change in pressure.
• Exposure to severe changes in atmospheric overpressure such as from an explosion.
• Scuba diving.
• Foreign objects such as using something to clean the ear canal.
• Slag injury is one of the rare, but unique causes. This is when a hot piece of metal or slag falls into the ear from welding, for example. This can cause permanent damage to the TM and to the middle ear bones. It can even cause damage to the facial nerve and cause facial weakness.

What does a tear in your eardrum feel like?

Whether from trauma or infection, universally a tear in the eardrum is painful and can be associated with a loud popping noise. If there is infection, as stated above, usually the pain precedes the perforation and there may even be a relief of the pain when the TM bursts. In cases where there is a fluid build-up or infection behind the TM, careful opening of the eardrum called a myringotomy and placement of a PE tube may cause pain relief and immediate return of hearing. These procedures can be done in the office with adults, and although the tradition has been doing them in the operating room for children, there are newer techniques being developed so that children can have the procedures in the office setting as well.

Traumatic TM perforations may be painful depending on the type of trauma. Hearing loss can be immediate, but it may also be minimal depending on the location of the TM perforation. Many traumatic TM perforations heal spontaneously even if they are large, but the healing may take 4-6 weeks. It is important to make sure the patient takes dry ear precautions and if there is water exposure or any sign of infection, antibiotic prophylaxis is important to consider.

Can a tear in the eardrum heal without even knowing about it?

Fortunately, the answer is yes. In fact, most patients I have seen that have a traumatic TM perforation have a healed eardrum by the time I see them in follow-up. A lot of patients report a sudden return of their hearing well before having any other problems.

TM perforations from water exposure can reoccur if the person continues to swim, surf, dive, or ride their wakeboard. Some patients can live in a cycle of the TM opening and closing depending on their activity. Large TM perforations may never heal on their own, but in those patients, I recommend no surgical repair until they are absolutely finished with their watersports for extended periods of time.

A final word about surgical repair of the eardrum

No repair is necessary of those patients who do not swim with minimal hearing loss and no history of recurrent ear infections. A hearing aid may be an option only if the hearing loss is significant and the patient does not want TM repair, or the TM does not heal properly.

Surgical repair may be done in the office or in the operating room, depending on the size and location of the TM perforation. There are many techniques available, most of which are extraordinarily successful.