Ruptured eardrum

In this article:

• What Is ruptured eardrum?
• Symptoms
• When to see a doctor
• Causes
• Infection
• Pressure changes
• Injury or trauma
• Complications
• Prevention
• Diagnosis
• References

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What Is ruptured eardrum?

Ruptured eardrum is the term for a tympanic membrane (TM) perforation, creating a hole between the external and middle ear. 

Tympanic membrane perforations (TMPs) can occur owing to various reasons. The  most common reasons include: 

1. Blunt trauma to the ear or nose
2. Barotrauma
3. Foreign objects stuck into an ear canal causing TM damage
4. Infection of the middle ear (otitis media) 

The tympanic membrane is highly sensitive to sudden changes in pressure in the external auditory canal and may get easily affected by these changes and get damaged. These perforations that occur are generally prone to spontaneous closure; however, the perforation size and possibility of spontaneous recovery are negatively correlated, and large perforations need longer recovery time

The TM is a layer of cartilaginous connective tissue, with skin on the outer surface and mucosa covering the inner surface that separates the external auditory canal from the middle ear cavity. The TM function is hearing transmitting those vibrations to the inner ear. When the tympanic membrane perforates, it may no longer create the vibrational patterns, leading to hearing loss in some instances.

Tympanic membrane rupture can occur at any age, although it is mainly seen in the younger population, associated with acute otitis media. As a patient’s age increases, trauma becomes a more likely cause of TM rupture. Men are more likely to experience TM perforation compared to women.

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Symptoms

The initial impact that ruptured the eardrum might be significantly more pronounced than after the TM already was ruptured. The first giveaway is a sharp severe pain inside the ear following an activity (scuba, shooting, working with a pneumatic gun etc.). Most people complain that they suddenly cannot hear from one or both ears. Later patients may have complaints such as pain, bloody discharge from the ear, and decreased hearing if perforation develops.

If an ear infection is responsible for a ruptured eardrum, the complains are:

•  Fever 
• Irritability and inconsolable crying in a child 
• Severe headache and earache in adult 
• Ringing in the ear (tinnitus) and dizziness or loss of balance may also be experienced.
• A pus or blood can be seen leaking out of an ear canal

It is common to experience a relief of pain and symptoms after TM is ruptured, as the pressure is now relieved.

When to see a doctor

Some ruptured membranes are missed until the hearing is affected. As such, it is a good idea to see a doctor if your hearing is suddenly going down. It is also a big concern if your child suddenly cannot hear. While most TM can heal without treatment, it is important to have care guidance to prevent an infection.

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Causes

TM perforations is a trauma of the eardrum, and a complication of:

• Infection (acute otitis media or otitis externa secondary to Aspergillus niger)
• Barotrauma from explosions, scuba diving, or air travel, sudden negative pressure
• Loud sound close to the ear

• Head trauma, noise trauma 
• Insertion of objects into the ear as an accident
• Iatrogenic complication of a medical procedure from attempting foreign body or cerumen removal. 

With acute otitis media (ear infection), the risk of spontaneous perforation increases with recurrent episodes caused by non-typeable Hemophilus influenzae. Rarely, it has also been seen as secondary to lightning strikes and electric current injury. There are risk factors for TM rupture, as well, such as prior ear surgeries, severe otitis externa, and prior or current otitis media.

Infection

In a recent review result of the bacterial culture in children with ruptured TM as a result of the ear infection are described and published in 2017:

Prospective evaluation of the aetiology of acute otitis media with spontaneous tympanic membrane perforation

P Marchisio , S Esposito , M Picca , E Baggi , L Terranova , A Orenti , E Biganzoli , N Principi , Milan AOM Study Group

 A single pathogen was identified in 70 (39.5%) samples, whereas two, three and four bacteria were detected in 54 (30.5%), 20 (11.3%), and 7 (4.0%) cases, respectively. Non-typeable H. influenzae was the most common and was identified in 90 children (50.8%), followed by M. catarrhalis (35.0%) and S. pneumoniae (27%). 

Non-typeable H. influenzae was the most frequent pathogen in children with co-infections. Children with co-infections, including non-typeable H. influenzae, had significantly more frequent recurrent ear infection (AOM).

Conclusions: Recurrent AOM episodes appear to be associated with an increased risk of AOM with STMP. In AOM with STMP, non-typeable H. influenzae is detected at a high frequency, especially in children with recurrent STMP and often in association with other pathogens.

Pressure changes

Perforation secondary to barotrauma is related to large or rapid changes in pressure gradients between the middle and external ear. For example, with scuba diving, the pressure in the middle ear is unequal to the pressure in the external auditory canal, creating an air squeeze. The difference across the membrane can ultimately lead to eardrum rupture.

In this situation it is important to prevent or treat nose congestion, which causes Eustachian tube dysfunction and disables a natural mechanism of the inner pressure normalization.

Injury or trauma

Traumatic TMP represents a common reason for evaluation in the ER. Traumatic TMP is commonly caused by barotrauma, a slap or strike to the ear, or penetration of the ear canal by foreign objects. Despite common warnings regarding risk of injury to the tympanic membrane with use of a cotton-tipped applicator, it is still a major cause of traumatic TMPs. Other injury mechanisms also play an important role in the teenage and young adult populations.

The study describes patients examined in the ER for ruptured TM of a university-affiliated medical center Tel Aviv, Israel between 2012 and 2016. 80 patients were reported with a mean age of 26.7 ± 14.6 years (20 children; 25%). TPTM was caused by blunt trauma in 45 patients (56%) and penetrating trauma in 35 patients (44%). 

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Complications

Overall, TM perforation has a favorable prognosis with a small risk of complications. Perforations tend to heal spontaneously without intervention. It is important to know when intervention and early referral is required, based on size, location, and symptoms associated with the perforation.

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Prevention

It is important to know about the activities that can lead to ruptured eardrum. Then it is possible to prevent a serious problem by following a simple safety recommendation. Here are some precautions:

• Always wear protective sound-blocking earmuffs or ear plugs when exposed to the loud sounds (construction, shooting, indoor concerts)
• Do not attempt to clean out wax with plastic or wood objects
• Teach kids not to put or stick objects into the ear canal (very common!)
• Prevent barotrauma in scuba diving by correct wear of equipment and following submergence protocols
• Use decongestant sprays and ear plugs on an airplane if congested and need to fly
• Offer a congested child to suck on the bottle of pacifier when flying or driving in the high altitude

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Diagnosis

Diagnosis is usually made in the ER or ENT clinic by a direct TM exam with otoscope. Eardrum perforations of <25% are classified as small tear, those of 25%-50% as medium perforations, and those of >50% as large perforations.

In questionable cases a pneumatic otoscope should be used which will demonstrate that the hole is present.

In cases of significant trauma of the head, an imaging study such as CT will help evaluate the damage of the skul and inner ear.

Hearing tests should be performed to assure that hearing is coming back as eardrum is healing.

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References

Lim DJ. Structure and function of the tympanic membrane: a review. Acta Otorhinolaryngol Belg. 1995;49(2):101-15. [PubMed]

Marchisio P, Esposito S, Picca M, Baggi E, Terranova L, Orenti A, Biganzoli E, Principi N., Milan AOM Study Group. Prospective evaluation of the aetiology of acute otitis media with spontaneous tympanic membrane perforation. Clin Microbiol Infect. 2017 Jul;23(7):486.e1-486.e6. [PubMed]

Pannu KK, Chadha S, Kumar D, Preeti Evaluation of hearing loss in tympanic membrane perforation. Indian J Otolaryngol Head Neck Surg. 2011 Jul;63(3):208-13. [PMC free article] [PubMed]

Bozan N, Kiroglu AF, Ari M, Turan M, Cankaya H. Tympanic Membrane Perforation Caused by Thunderbolt Strike. J Craniofac Surg. 2016 Nov;27(8):e723-e724. [PubMed]

Carniol ET, Bresler A, Shaigany K, Svider P, Baredes S, Eloy JA, Ying YM. Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments. JAMA Otolaryngol Head Neck Surg. 2018 Feb 01;144(2):136-139. [PMC free article] [PubMed]

Adegbiji WA, Olajide GT, Olajuyin OA, Olatoke F, Nwawolo CC. Pattern of tympanic membrane perforation in a tertiary hospital in Nigeria. Niger J Clin Pract. 2018 Aug;21(8):1044-1049. [PubMed]

Sagiv D, Migirov L, Glikson E, Mansour J, Yousovich R, Wolf M, Shapira Y. Traumatic Perforation of the Tympanic Membrane: A Review of 80 Cases. J Emerg Med. 2018 Feb;54(2):186-190. [PubMed]