Traumatic perforation of tympanic membrane

Red flags

  • Significant generalised head- or polytrauma – use the ATLS approach
  • Battle's sign – ecchymosis (bruising) behind the ear can be a sign of skull base fracture
  • Facial nerve palsy

 

When to involve the ENT registrar

  • Immediately: Temporal bone fracture with facial or other lower cranial nerve palsy
  • Soon/next working day: Temporal bone fracture without any neurological signs

 

Who to admit

  • If other traumatic injuries are excluded, patients with an isolated tympanic membrane perforation do not require admission

 

Assessment and recognition

Tympanic membrane perforations commonly arise as a result of blunt force trauma to the external ear canal (eg road traffic collision; blow to side of head). There can also be penetrating trauma (cotton buds, iatrogenic injury during microsuction) and barotrauma (explosions, scuba diving). Patients may present with otalgia, hearing loss, aural fullness, tinnitus and serosanguinous discharge. There is a theoretical risk of secondary infection.

For any patients with cranial nerve palsy, fluctuating GCS or other neurological signs, consider the need for a CT brain/temporal bones. Depending on the result, you may need to involve the ENT or neurosurgical registrars.

 

Immediate and overnight management

  • ABCDE assessment as per Advanced Trauma Life Support (ATLS) protocol if indicated by mechanism of injury
  • Full otoscopic examination including documenting the correct ear and location of the perforation (use a clockface)
  • Rinne and Weber's tests provide rapid bedside assessment of hearing status but are not very reliable
  • Document facial nerve and lower cranial nerve function
  • Consider topical antibiotic drops if there is contamination eg soil; we do not recommend antibiotic drops for dry, uncontaminated perforations (it is normal to see a little blood!)
  • If there is a lot of blood clot in the canal, instil some saline or sodium bicarbonate drops to try to improve your view; it is unusual for isolated tympanic membrane perforations to bleed a lot, so suspect a more extensive injury
  • Advise the patient to keep the ear clean and dry as getting the ear wet increases the chances of a secondary infection
  • When showering with shampoo or soap, use water precautions such as a soft ball of cotton wool rolled in petroleum jelly and placed gently against the canal (detergents reduce the surface tension of the water and makes it more likely to pass through the perforation and into the middle ear)
  • Advise the patient to attend their GP/local walk-in centre for ear drops if they develop ear discharge and pain

 

Further management

Patients with isolated, uncomplicated, dry perforations normally recover spontaneously: specialist follow-up is not routinely required. 

You can advise patients that the majority of perforations heal within eight weeks. One study of 114 patients found that 72% of small and medium-sized perforations had healed by four weeks with 70% of large perforations healed by 8 weeks (1). If they keep their ear dry and there are no infections, patients do not necessarily need to see their GP.

In contrast, if patients get recurrent ear discharge or their hearing is persistently poorer than before the injury, they should seek a referral to the ENT clinic. 

For more complex patients eg presence of temporal bone fracture or pre-existing poor hearing, arrange an ENT emergency clinic appointment one week after injury. The perforation can be re-assessed under the microscope and the patient may also have Pure Tone Audiogram (PTA).

Non-healing perforations in the presence of persistent hearing loss or recurrent infections may require surgical repair (myringoplasty). 

 

References

(1) Lou ZC et al. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin Otolaryngol. 2011 Aug; 36:450-60.

 

 

Page last reviewed: 4 March 2017