What Is an Eardrum Perforation?

An eardrum perforation, also known as a tympanic membrane rupture, is a tear or hole in the thin tissue that separates the ear canal from the middle ear. The eardrum is essential for normal hearing; it vibrates when sound waves enter the ear and transmits these vibrations to the ossicles, the tiny bones of the middle ear. When the eardrum is perforated, hearing can be affected, and the middle ear becomes more vulnerable to infection.

Common Causes of a Ruptured Eardrum

There are several ways the eardrum can be damaged. The most common causes include:

• Middle ear infections, particularly acute otitis media, which can cause fluid and pus to accumulate and put pressure on the eardrum until it ruptures.
• Barotrauma, which is pressure imbalance between the inside of the ear and the environment, often caused by rapid altitude changes during air travel, scuba diving, or a forceful blow to the ear.
• Acoustic trauma from extremely loud noises, such as an explosion or a gunshot fired close to the ear.
• Inserting objects into the ear, such as cotton swabs, hairpins, or pens, which can puncture the eardrum.
• Head trauma, including a skull fracture, which can disrupt the structures of the middle ear.

Symptoms of Eardrum Perforation

The symptoms of a perforated eardrum can vary depending on the size and location of the tear. Many people notice sudden ear pain that may lessen once the eardrum actually ruptures. Other symptoms include:

• Hearing loss, which may be mild to severe and is often temporary.
• Otorrhea, or discharge from the ear, which may be clear, bloody, or pus-like if an infection is present.
• Tinnitus, experienced as ringing, buzzing, or hissing in the ear.
• Vertigo or dizziness, related to the balance organs near the eardrum and middle ear.
• A sensation of fullness or pressure in the ear.
• Weakness in the facial muscles in rare cases if the perforation is large and the facial nerve is affected.

Diagnosis of a Perforated Eardrum

A healthcare professional can usually diagnose an eardrum perforation during an otoscopic examination. An otoscope allows the clinician to look into the ear canal and see the eardrum directly. The examination may reveal a visible tear, hole, or the presence of fluid behind the eardrum. Additional tests may be performed to assess the impact of the perforation:

• Audiometry, a formal hearing test, helps quantify the degree of hearing loss.
• Tympanometry evaluates how well the eardrum moves in response to air pressure changes.
• If an infection is present, a sample of the ear discharge may be sent for laboratory culture to identify the responsible bacteria or fungi.

In cases of persistent or complex perforations, imaging studies may be recommended to check for cholesteatoma, an abnormal skin growth in the middle ear that can cause damage and chronic discharge.

Healing and Nonsurgical Treatment

Many small eardrum perforations heal on their own within a few weeks, especially if the ear is kept dry and free from further trauma. During the healing period, it is important to avoid water entering the ear, so swimming or showering may require a waterproof plug. Patients are also advised to avoid forcefully blowing the nose, because this can push bacteria and mucus into the middle ear.

If there is evidence of infection, oral antibiotics or antibiotic ear drops are commonly prescribed. Analgesics may help relieve ear pain. Occasionally, a clinician will place a paper patch over the tear to encourage and guide the natural healing process. This simple office procedure, sometimes called patching, can work well for small perforations.

Surgical Repair: Tympanoplasty and Myringoplasty

If a perforation is large, does not heal after several months, or is associated with conductive hearing loss, surgery may be necessary. Tympanoplasty is a surgical procedure in which graft tissue, often taken from the patient's own fascia or cartilage, is used to reconstruct the eardrum. Myringoplasty is a similar, more limited procedure used specifically to close a small hole in the eardrum. These operations are generally performed under local or general anesthesia and carry high success rates for restoring the integrity of the eardrum and improving hearing.

During surgery, the surgeon may also address any underlying problems in the middle ear, such as chronic otitis media, damaged ossicles, or cholesteatoma. After surgery, the ear is packed to protect the reconstructed eardrum, and a period of healing and follow-up is required.

Complications and Prevention

If left untreated, a perforated eardrum can lead to complications. Recurrent middle ear infections are common because the eardrum normally acts as a barrier. Chronic suppurative otitis media may develop, characterized by persistent drainage and tissue damage. A large perforation can also contribute to permanent hearing loss, particularly if the ossicles are damaged. In rare cases, the infection can spread to the inner ear or the mastoid bone, causing more serious illness.

Preventing eardrum perforation involves protecting the ears from trauma and pressure changes. Avoid inserting any objects into the ear, especially cotton swabs. Use proper ear protection during loud activities and use earplugs while flying or diving to equalize pressure. Promptly treating ear infections can also reduce the risk of rupture.