Tympanic membrane perforation: symptoms and causes

An eardrum perforation is a lesion in the tympanic membrane located between the outer ear and middle ear.

The ear consists of three parts:

  • The outer ear is the visible part of the ear, i.e. the auricle and earlobe together with the ear canal, which extends to the eardrum.
  • The middle ear lies behind the eardrum and consists of a small air-filled cavity containing the three ossicles: anvil, hammer and stirrup.
    The Eustachian tube or auricular tube is a tube that connects this cavity to the nose and throat.
  • The inner ear consists of a bony labyrinth containing the organs of hearing and balance:
    • cochlea (snail-shaped structure with two fluid-filled chambers),
    • Vestibular apparatus.


Tympanic membrane – structure and function

The tympanic membrane is a thin membrane of oval shape, located at the end of the external auditory canal.
The eardrum owes its name to its shape, which is reminiscent of a drum.
Components of the tympanic membrane:

  • Tensioned part or pars tensa, consisting of three layers:
    • an outer thin layer of skin (stratum cutaneum),
    • a fibrous layer (lamina propria), which gives the structure a certain rigidity,
    • an inner thin mucosal layer (stratum mucosum).
  • Flaccid part or pars flaccida, which does not contain a fibrous layer.

The eardrum separates the middle ear from the outer ear and protects the internal structures.

The tympanic membrane (membrana tympani) has two main tasks:

  1. Hearing. The main function of the tympanic membrane is to transmit the sound waves from the outside world to the ossicles in the middle ear. When the sound waves hit the eardrum, it vibrates and transmits the vibration to the other structures of the middle ear. In this way, the sound waves reach the cochlea and are converted into nerve impulses that reach the brain.
  2. Protection. The eardrum also acts as a barrier by protecting the middle ear from water, bacteria, and other foreign bodies that can favor the development of infection.

If an eardrum perforation is not treated, unpleasant symptoms can occur and lead to serious complications.

If an eardrum perforation is not treated, unpleasant symptoms can occur and lead to serious complications.

In this picture, the outer edge of the tympanic membrane is not affected, the ring (anulus) is present, the perforation is therefore paracentral.The perforation is located in the lower area, so you can not see the ossicles, which are located in the upper part.
On the right image you can see a paracentral, posterior perforation. Behind the eardrum you can see:

  • the round window,
  • the end of the anvil lentil bone process,
  • part of the stirrup.

The white spots are limescale deposits.

In this photo, the perforation is much larger and has eroded almost the entire eardrum.Through the opening in the eardrum you can see:

  • the free hammer handle (manubrium), as it is no longer connected to the eardrum,
  • the anvil,
  • part of the stirrup,
  • the round window,

the canal of the facial nerve or facial canal.

Causes of tympanic membrane perforation

The causes of a ruptured or perforated tympanic membrane include:

    • Infections of the middle ear (otitis media). Infection of the middle ear leads to inflammation of the middle ear and accumulation of fluid. The pressure of this fluid can lead to rupture of the tympanic membrane. Ear infections are very common in children and infants.
      With severe otitis, other symptoms may appear:

  • Barotrauma of the ear. Barotrauma is damage to the tissues of the ear caused by air pressure. Barotrauma occurs when the pressure in the middle ear and the air pressure of the environment are not balanced. If the pressure difference is significant, the tr denommelfell may burst.
    Barotrauma often occurs due to changes in air pressure in connection with:

    • Flights
    • Dives.
  • Loud sounds or a bang (sound trauma). A loud sound or bang (sound waves caused by an explosion, the bang when opening an airbag in a car, or a gunshot) can cause injury to the eardrum.
  • Foreign body in the ear. Small objects (such as a cotton ball or hair clip) can perforate or injure the eardrum.
  • Severe trauma. Severe craniocerebral trauma (such as a fracture of the skull or a vigorous slap) can cause displacement or injury to the structures in the middle and inner ear, including the eardrum.

Symptoms of tympanic membrane perforation

Symptoms of a ruptured tympanic membrane include:

  • Earache. The intensity of pain varies from person to person, depending on the severity of the rupture of the tympanic membrane.
    Some people may only feel an impairment, while others may feel severe pain.
  • Secretions from the ear. If the eardrum is perforated, fluid leakage from the ears may occur. This discharge may look clear, but it may also contain blood.
  • Tinnitus (noise in the ears). If damage occurs to the eardrum, you can hear a buzzing, ringing and whistling in the ears.
  • Dizziness or vertigo. This symptom may be accompanied by nausea and vomiting.
  • Hearing loss. If the eardrum is perforated, it loses the ability to vibrate and thus transmit the sound waves to the brain. Consequently, the person is unable to hear sounds and voices. With a slight perforation of the tympanic membrane, hearing loss is small and also temporary; the situation normalizes when the damage is healed. If, on the other hand, the damage is severe, the possibilities of restoring a person’s hearing are much lower.

Complications of tympanic membrane perforation

In most cases, a ruptured eardrum grows back together on its own; however, with a large damage, complications may occur.

The possible consequences include:

  • Hearing loss. Typically, hearing loss is temporary and lasts until the injury or hole in the eardrum heals. The extent and location of the injury can affect the degree of hearing loss. With a large perforation, the patient suffers a serious reduction in hearing.
  • Infection of the middle ear (otitis media). An eardrum perforation can allow bacteria to enter the ear. If a perforated eardrum doesn’t heal or don’t close, the ear can be susceptible to chronic infections that can lead to permanent hearing loss.
  • Cholesteatoma. A cholesteatoma is a cyst in the middle ear consisting of epithelial cells and decay products.
    Usually, decay products shift towards the outer ear, because when the epithelial cells of the ear canal split off, they migrate to the auricle, i.e. outwards. If the eardrum is rupture, the skin cells can also penetrate the middle ear and grow there. Here is the mucous membrane of the respiratory system, which has different characteristics than the skin, in fact, it does not flake. The accumulation of scales caused by the new epithelium forms the cholesteatoma.
    A cholesteatoma creates a favorable environment for bacteria and contains enzymes that can damage the bones in the middle ear.

Diagnosis of eardrum perforation

Physical examination
Often, the family doctor or ear doctor can determine whether there is a rupture of the eardrum by using a special instrument (otoscope).
The injury to the tympanic membrane is easily detectable with an otoscope.

The doctor may order further examinations or perform them themselves to determine the cause and extent of the injury. These investigations include:

  • Laboratory tests. If there is discharge, the doctor can take a swab, that is, take material from the ear and examine it to detect a bacterial infection of the middle ear.
  • Tympanometry. Tympanometry uses a device that is inserted into the ear canal and produces pressure variations to measure the responses of the tympanic membrane to slightly altered barometric pressure.
  • Audiometric examination. The doctor may order an audiological examination, which is a series of tests performed in a soundproof booth that measure hearing at different volumes.

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