Eardrum Perforation

What is an eardrum perforation?

The eardrum is a thin membrane that separates the outer ear canal from the middle ear. It vibrates with sound waves, plays a part in hearing and protects the middle ear from the outside. An opening in this membrane is called an eardrum (tympanic membrane) perforation.

A perforation can be caused by a middle ear infection that bursts the eardrum under pressure, objects pushed into the ear, sudden pressure changes such as a slap or an explosion, pressure injuries during diving or flying, or an opening that stays after a ventilation tube comes out. Perforations can also occur with long-standing middle ear disease.

Symptoms and reasons to see a doctor

Symptoms depend on the size, position and cause of the hole. A small perforation may cause no complaints at all and only be noticed at an examination for another reason.

• Reduced hearing
• A feeling of fullness or blockage in the ear
• Recurrent or persistent ear discharge
• Infections that start particularly after water gets into the ear
• Sudden pain, bloody discharge or ringing in the ear after an injury
• Dizziness in some patients

Examination and diagnosis

The diagnosis is made by ENT examination. The eardrum is examined with an otoscope and, where needed, in detail under a microscope (otomicroscopy) to assess the size and position of the perforation, the state of its edges and whether there is infection in the middle ear.

A hearing test (audiometry) shows how much hearing is affected. Where relevant, additional tests such as tympanometry, which measures middle ear pressure and eardrum mobility, are used. In selected patients — for example with long-standing discharge, more hearing loss than expected or suspicion of other middle ear disease — a CT scan may be requested. These findings guide the choice of treatment.

Treatment options

Not every perforation needs surgery. Small holes caused by injury or infection in particular can close on their own within weeks, as long as the ear is kept dry and any infection is controlled. Follow-up visits are arranged at the intervals your doctor recommends.

If there is discharge, the infection is treated first with drops or medication prescribed by the doctor. Keeping water out of the ear is important during this time. For some small perforations, simple repair methods carried out in the clinic may also be considered.

For perforations that do not close, or that cause repeated infections or hearing loss, the operation to repair the eardrum — tympanoplasty — is considered. Surgery is planned for a time when the ear is dry and free of infection.

How is tympanoplasty done?

Tympanoplasty is usually performed under general anaesthesia with an operating microscope. The hole is closed with the patient’s own tissue, most often a thin layer of muscle covering (fascia) or cartilage taken from around the ear. This graft is placed under or over the eardrum and acts as a framework on which the new membrane grows as it heals.

Depending on the position and size of the hole and the shape of the ear canal, the surgeon works either through the ear canal or through an incision behind the ear. If there is a problem with the small bones of the middle ear, it can be assessed during the same operation. The operation usually takes about one to two hours; the exact time is confirmed at the consultation. Most patients go home the same day or after one night.

Recovery

Recovery varies with the person and the procedure. The timeline below is a general guide.

1. Day 1There is packing in the ear canal and a dressing over the ear. Mild pain, a feeling of fullness and reduced hearing are normal. Brief, mild dizziness can occur.
2. Week 1No water must get into the ear; in the shower the ear is protected as your doctor advises, for example with greased cotton wool. Avoid blowing your nose and sneeze with your mouth open. Avoid heavy lifting and straining. If there is an incision behind the ear, the stitches are checked at follow-up.
3. Weeks 2–4The packing in the ear canal is cleaned out at a follow-up visit at the time your doctor decides. The ear is still kept dry. Wait for your doctor’s advice before flying, diving or swimming.
4. 1–3 monthsThe new membrane gradually matures and is checked under the microscope at follow-up. Any change in hearing is assessed with a hearing test once the eardrum has healed, usually after a few months.
5. Later onWhen you can return to swimming, diving and other activities that expose the ear to water or pressure is decided by your doctor based on how it has healed.

Risks and how they are reduced

Tympanoplasty is a commonly performed ear operation, but it does carry some risks. The graft may not take and the hole may reopen; there may be infection, temporary or longer-lasting dizziness, ringing in the ear and a change in taste on one side of the tongue. The taste change is related to a nerve branch that runs through the middle ear and in most patients improves over time. Rarely hearing may be reduced, and very rarely there may be problems with the facial nerve.

To reduce risks, surgery is planned when the ear is dry and free of infection, and it is performed under the microscope with careful handling of the ear structures. After surgery, keeping water out of the ear, not blowing the nose and attending follow-up visits help the graft to take. If you notice severe dizziness, increasing pain, fever, foul-smelling discharge or weakness in the face, contact your doctor without delay.

Everyday care

While there is a hole in the eardrum, water entering the ear increases the risk of infection. Protect the ear when bathing and ask your doctor before swimming in a pool or the sea. Do not put cotton buds or other objects into the ear canal. If you notice discharge, pain or a sudden drop in hearing, arrange an examination promptly.