A tympanic membrane perforation represents a hole in the eardrum establishing a communication between the middle and external ear.
There are two general types, which are distinguished by the area of the eardrum involved. A central perforation (most common) can involve any portion of the drum as long as a portion of the tympanic membrane surrounds the hole. A marginal perforation involves the edge of the eardrum (tympanic annulus).
A tympanic membrane perforation must be distinguished from a retraction pocket, which is typically an involution of a portion of the intact tympanic membrane and can be a harbinger of cholesteatoma.
Treatment of central and marginal perforations is the same.

Initial Diagnosis and Management

History: Key factors to elicit in the history include the etiology of the perforation, the duration of the perforation, and associated symptoms including hearing loss, otorrhea, vertigo, and tinnitus. Common etiologies include acute or chronic infection, eustachian tube dysfunction, trauma, and previous ear surgery (including PE tube placement). Typically, tympanic membrane perforations heal on their own over the course of 1-4 months, especially if they developed from an acute process. Chronic disease is more likely to require intervention.
Physical: The physical exam should confirm the existence of a perforation vs. a retraction pocket, as well as describe the perforation's size and location. The size is given as a percentage of the drum surface, and the location describes the quadrant of the drum. For example: a 25% central perforation in the anterior inferior quadrant. On pneumotoscopy the TM will not move if there is a perforation. If there is movement, the diagnosis of a TM retraction should be suspected. An examination of the middle ear mucosa should be performed through the perforation to document any pathology (cholesteatoma, infection, etc). Typically with an infection there will be discharge visible in the external ear and the mucosa will look pale and friable. Rinne & Weber tests are always indicated with a 512Hz tuning fork to document hearing loss.
Ancillary Tests: An audiogram should be obtained to document and quantify any hearing loss. This is especially important in the trauma setting as well as in chronic infection.
Initial Management: Management strategies are initially focused on the etiology. Acute and/or chronic infections as well as eustachian tube dysfunction should be treated medically. The majority of tympanic perforations undergo spontaneous closure with conservative care. Patients should be instructed to keep water out of the ear during healing especially during bathing and swimming. Patients may use a large cotton ball saturated with Vaseline (petrolatum) jelly placed onto the outer ear opening to prevent water from entering the ear.

Ongoing Management and Objectives

Ongoing management should focus on prevention of infection and documentation of spontaneous perforation closure.

Indications for Specialty Care Referral

An audiogram showing conductive hearing loss associated with a TM perforation.
Traumatic perforation with any of the following: flap of TM into middle ear, vertigo, or hearing loss. Call ENT Clinic and refer immediately.
Recurrent middle ear infections associated with a TM perforation.
Patient desires to participate in water activities AND surgical correction with an otherwise stable perforation without infection or hearing loss.

Criteria for Return to Primary Care

Resolution of the problem by medical or surgical therapy.

Last Review for this Guideline: May 2009
Referral Guidelines require review every three years.

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