Condition: Traumatic tympanic perforation



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Condition: Traumatic tympanic perforation

Definition:

Tympanic membrane, or eardrum, is a stiff but movable oval membrane inside the ear. It separates the outer ear canal from the inner ear. A perforation involves a tear or hole in the tympanic membrane. As a result of this perforation a conductive hearing loss may result (Berger, 1989). There may also be ear discharge, tinnitus (ringing or buzzing sound in the ear), or dizziness. This discharge may be clear, bloody, or yellowish and thick (Wolters Kluwer April 2010.)

Perforation of the tympanic membrane refers to either a “partial” or total hole in the tympanic membrane. It represents a hole in the eardrum establishing a communication between the middle and external ear (Ibekwe et. al, 2007). Perforation of the tympanic membrane produces a conductive hearing loss in the affected ear (Berger G 1989).



Path physiology:
Perforations may spontaneously heal within time but in the case of traumatic perforations a tympanoplasty may be performed to reduce the risk of infection (Omadasun, 2002) (Merwin & Boies, 1980). Larger perforations are usually associated with chronic infections of the middle ear space and these may be more likely to require surgical intervention (Gelfand, 2009). Sub categories include marginal, central and attic perforations. Marginal perforations involve the fibrous annulus, and central perforations do not involve the fibrous annulus (Oghalai, 2006). Perforations classed as an ‘attic perforation’ usually involve the Pars flaccid (Gelfand, 2009). Central perforations seem to be most common type (Legget, 2010) and one reason for traumatic perforations are from “Overpressure”, such as those caused by a hit. (Afolabi et. al, 2009)

The result of tympanic membrane perforation results in a conductive hearing loss. This occurs because the advantages of ratio between the area of the tympanic membrane and the oval window is reduced, decreasing the vibrations transmitted (Gelfand, 2009 pp 171). Consequently the area to ratio difference between the tympanic membrane and oval window is also reduced. Whereas a fully intact membrane would give an approximate pressure gain at the oval window of times twenty, a perforated eardrum would not provide the same pressure gain. This means a significant amount of the impedance matching property of the middle ear is reduced. The malleus is attached to the tympanic membrane by the fibrous layer (Howard, 2009) and a perforation can affect this attachment by reducing the vibrations transmitted by the ossicular chain (Gelfand, 2009, pp171). A healed perforation can form a neomembrane which is a thin membrane made up of mucosal and ‘squamous epithelia layers’, with no fibrous layer present (Howard, 2009). These neomembranes are often mistaken for perforations because the membrane is so thin or because they have retracted in to the middle ear (Howard, 2009). They should not be confused with perforations.

Perforations due to burns can often become infected and the patient may experience otorrhea. Trauma to the tympanic membrane and the middle ear can be caused by overpressure slap on the ear, fight, assault and road traffic injury, Thermal or caustic burns, penetration by instruments and barotraumas. The thermal injury was caused by metal spark perforating the tympanic membrane during welding. (Naumann et al 1998, pp136) (Kyoo Sang Kim Tae Jung 1999).
Symptoms:-

Symptoms vary between individuals and depend on the size and location of the perforation (Gelfand, 2009).


  • Tinnitus

  • Sudden hearing loss (Afolabi et. al, 2009)

  • Otalgia (ear pain)

  • Bleeding

  • Potential infection of the middle ear (Amadasun, 2002)

Epidemiology: - Traumatic perforations are usually caused by a sudden force, change of pressure or object that is substantial enough to create a hole in the eardrum (Greenburg, et. al, 2005).

Common causes include:



  • Accidental or purposeful insertion of an object into the external auditory meatus (EAM) such as a pencil or sewing needle (Oghalai, 2006)

  • Sudden force such as a jet of water (Shanks & Shohet, 2009), a slap to the nose (Amadasun, 2002), or as a result of an explosion (Kronenberg et.al, 1993)

  • Pressure changes between the environment and ear; barotruama,

  • Ear syringing or suctioning (Amadasun,

  • Thermal injury was causes by metal spark perforating the tympanic membrane during welding. (Kyoo Sang Kim Tae Jung 1999)

  • Surgical removal of foreign bodies

  • Infections such as purulent acute otitis media and chronic otitis media (Berger G.1989.)

  • Trauma to the tympanic membrane and temporal bone (Berger G.1989)

  • Latrogenic - myringotomy with tympanostomy tube placement (Berger G.1989.

Perforations can affect any one of any age and this is unpredictable due to the sudden nature of the perforation. However it is more common in certain groups of people.



  • Traumatic perforation of the tympanic membrane has been reported to occur in up to 36.5% of those injured by terrorist attacks and up to 63.2% of casualties following an explosion (Cooper, et. al, 1983, cited in Kristensen, 1992)

  • Estimates of the prevalence vary with estimates ranging from 1.4 to 8.6 per 100,000 people (Griffin, 1979 & Kristensen et. al, 1989, cited in Kristensen, 1992)

  • A blow to the head and neck can also lead to a traumatic perforation, with Thermal burns that result in perforations are more prevalent in occupations such as welders (Naumann et.al, 1998, pp136)

  • Perforations as a result of a sudden blast or explosion are more common in times of unrest or war (Kronenburg et. al, 1993)

  • Those caused by a sudden force such as a slap may be associated with assault (Glasscock, M.E. & Gulya, A.J., 2003). Estimates suggest that up to 50% of abusive injuries to this head and neck result in a perforation.

Management:

As up to 94% of perforations heal naturally (Berger, G, & Gelfand, 2009) medical intervention is not usually necessary. In these situations monitoring of the perforation is usually sufficient. However it is necessary in some cases to intervene and options include:



  • Using a specialised plug with a topical antibiotic to prevent an infection (Omadasun, 2002)

  • Ensuring the ear is kept dry to discourage bacteria from growing in the warm and moist conditions (Chukuezi, A.B. & Nwosu, J.N, 2009)

  • Surgery such as a tympanoplasty or myringoplasty for larger perforations (Gelfand, 2009). Both involve using a tissue graft to repair the perforation. Surgery may also prevent future ear infections (Moller, 1988-1997)

  • Pain killers may be given to reduce the pain (Wolters Kluwer April 2010.)

There is some evidence that treating tympanic membrane perforations surgically may resolve symptoms, improve the patients hearing, and may prevent further ear infections (Moller, A.R., 2006)


CONDITION: Traumatic (tympanic) perforation in left ear


Otoscopy result


Notes: - The right tympanic membrane appeared to be normal under otoscopy. The left ear was noted to have a central perforation in the inferior posterior part of the tympanic membrane beside the Umbo. Otoscopy can also be useful in order to reveal the cause of the perforation, traumatic perforations usually have sharp ragged edges and blood can often be see in the EAM or middle ear (Naumann et al 1998, pp136). Sub categories of TM perforation include 1) Marginal, 2) Central and 3) Sub total central - This term is used by some ENT surgeons in the UK and refers to a very large central perforation surrounding one side of the umbo, Central perforation seems to be most common (Legget, 2010. Basic Path physiology slides).


Other potential otoscopy findings

1) Safe perforation of the anterior part of the drum, a common cause of perforations in this position is a persistent defect after the extrusion of a grommet (Saunders, M, 2003)









2) Inferior perforation, this is more likely to be as a result of chronic middle ear infection (Saunders, M, 2003)





3) Posterior perforation, although posterior perforations may represent more serious diseases such as cholesteatoma, this is well described and dry. It is possible to make out the posterior margin of this defect. Traumatic perforations (e.g. barotraumas) are often posterior and liner, like a tear rather than a round hole.
(Saunders, M, 2003)

Perforation





Weber:


Lateralises to the left



Rinne:

Right ear
positive


Left ear
negative





Tuning forks (non central perforation






Notes: The Weber test shows lateralisation to the left side with conductive hearing loss. The Rinne result for the right ear indicates that the sound was heard better by air conduction than bone conduction. The negative left Rinne shows that the sound was perceived to be better via bone conduction than air conduction. Both tests results suggest CHL on the Left.



Pure tone audiometry and uncomfortable loudness levels (non central perforation)


Notes: PTA results indicate a unilateral mild-moderate sloping mixed hearing loss; masked bone conduction was required at 500Hz, 1000Hz, 2000Hz and 4000Hz in the left ear, due to the presence of an air-bone gap of more than 10dB. A large air bone gap in the suspect ear could indicate the incidence of ossicular chain disruption caused by the perforation. Profound sensor neural hearing loss (SNHL) in the suspect ear could indicate labyrinthine window rupture caused by the perforation (Milchard, 2009; Naumann et al 1998, pp136 & Katz, et al., 2009).




Tympanometry
Right Left

Notes: A 226Hz probe was used at all times using the diagnostic mode at a rate of 50da pa per second. Flat trace for left ear is the expected result for a left TM perforation. The abnormally high ear canal volume result (above 2.0ml) for the left ear supports the otoscopy findings that show a small central inferior posterior perforation. This is as the volume of the middle ear cavity has also been recorded.

The right ear has results within the normal range, of between -50 and +50 daPa for middle ear pressure and between 0.3-1.6 ml for middle ear compliance.



Acoustic reflexes (central perforation)
Threshold

Right

Stimulus ear

Left

Contra lateral

Ipsilateral

Stimulus

Ipsilateral

Contra lateral

> 100 dB

80

500Hz

> 100 dB

80

> 100 dB

85

1000Hz

> 100 dB

90

> 100 dB

90

2000 Hz

> 100 dB

85

> 100 dB

85

4000 Hz

> 100 dB

80

> 100 dB

65

BB Noise

> 100 dB

70

Notes: Reflexes could not be obtained for the ipsilateral left reflex or the contra lateral right reflex because we stop increasing the intensity of the stimulus if there is no result for 100 dBHL. The reason for the absences is because of the ‘probe ear and stimulus ear principles’ (Katz et. Al 2009). These state that if there is a conductive hearing loss in the probe ear, then the acoustic reflex of that middle ear will be absent. Results from the contra lateral left and ipsilateral right reflexes are within the normal threshold range of 75-90 db for pure tones and 50-75db for broad band noise.


Differential diagnosis: Left facial nerve paralysis results might be almost identical to these expected results. Acoustic reflex results are not sufficient to diagnose TM perforations, however when combined with the other test results, particularly otoscopy results, correct diagnosis of TM perforation should be straightforward. (Aage R. Moller 1988-1997).


Otoacoustic emissions


N/A



N/A


Notes:

Transient Evoked Otoacoustic emissions (TEOAE’s) testing was carried out between 500 Hz to 4 kHz. ILO 292 measurement system was used. A standard non-linear stimulus paradigm was used at a rate of 50 clicks per second in order to minimise the risk of stimulus artefacts. Definition of a present TEOAE was based on the reproducibility percentage with values above considered to be a possible TEOAE, above 75% a definite TEOAE and below 50% the procedure was repeated once and then deemed to be too noisy to obtain an accurate measurement. It was also based on the dispersion of the TEOAE waveform with high frequency components appearing first, followed by low frequency components. The overall shape of the OAE was also taken into account. This test is particularly useful in children, as it does not require patient response (OAE Guide, 2009)


The detection of distortion-product otoacoustic emissions depends on the viability of the ear's conduction apparatus. However, tympanic membrane perforations and other conductive disorders have not been fully investigated with regard to the examination.

General comments

Treating your tympanic membrane perforation may resolve your symptoms, improve your hearing, and prevent further ear infections. Therefore if medicines do not work, you may need surgery such as a tympanoplasty or myringoplasty. Both surgeries are done to repair your eardrum hole using a tissue graft. A tympanoplasty is done if you also have damage to your inner ear (Wolters Kluwer April 2010.)

Not treating your perforated eardrum may cause worsening or permanent hearing loss. You may have chronic repeat ear infections. The tear or hole in your eardrum may get bigger. Water may enter through the hole in your ear causing infection and damage to your inner ear. You may not be able to do activities you enjoy such as swimming, diving or surfing. A severe ear infection may spread to your head, neck, and brain, and you may die (Wolters Kluwer April 2010.)

Medicines used to treat your tympanic membrane perforation may cause dizziness, vomiting (throwing up), or loose bowel movements. Medicines may also cause an allergic response and you may have trouble breathing. Ear drop antibiotics may damage your inner ear if you use them for longer than ordered. Surgery may cause you to have bloody discharge from your ear. Surgery may also cause you to have ear pain and you may get an infection. The tissue graft used to cover the hole in your eardrum may also become infected. (Wolters Kluwer April 2010)



References:
Berger G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. J Laryngol Otol. 1989 Dec;103(12):1150-3.

Amadasun, J.E.O., ‘An observational study of the management of traumatic TM perforations’, The Journal of Laryngology & Otology, March 2002, Vol. 116



Oghalai, J.S., 2006, ‘TM, middle ear and mastoid disease’, Baylor College of Medicine, Otolaryngology- head and neck surgery, Retrieved 28th February 2010 http://www.bcm.edu/oto/jsolab/tm_me_mastoid/tympanicmembrane.htm

Shanks, J & Shohet, J, 2009, J Katz, L Medwetsky, R Burkard & L Hood, Handbook of Clinical Audiology, 6th edn., Gelfand, S.A., 2009, Essentials of Audiology, Thieme Medical Publishers Inc., New York, USA, pp 172

Kronenberg, J, Ben-Shoshan, J & Wolf, M, ‘Perforated TM after blast injury’,
Kristensen, S, ‘Spontaneous healing of traumatic tympanic perforation in man: A century of experience’, The Journal of Laryngology and Otology, Vol. 106, 1992, pp 1037-1050, retrieved 1st March 2010 http://journals.cambridge.org/download.php?file=%2FJLO%2FJLO106_12%2FS0022215100121723a.pdf&code=576126299d8f703f74f024857fd4885c

Ibekwe, T.S., Ijaduola, G.T.A., Nwaorgu, O.G.B., ‘Tympanic perforation among adults in West Africa’, Otology & Neurotology, 2008 Vol. 28, pp 348- 352


Afolabi, O.A., Aremu, S.K., Alabi, B.S. & Segun-Busari, S, ‘TM membrane perforation: An aetiological BMC Research Notes 2009, retrieved 28th February 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785833/pdf/1756-0500-2-232.pdf

Chukuezi, A.B. & Nwosu, J.N., ‘An unusual cause of acute TM perforation: a case report’, International Journal of Medicine and Medical Sciences, Vol 1(4), 2009, pp 97-98, retrieved 28/02/2010 from:


http://www.academicjournals.org/ijmms/PDF/pdf2009/Apr/Chukuezi%20and%20Nwosu.pdf

Naumann, H.H., Helms, J, Herberhold, C, Jahrsdoerfer, R.A., Kastenbauer, E.R., Panje, W.R. & Tardy Jnr., M.E., 1996, Head and neck surgery: Volume 2: the Ear, Thieme Medical Publishers Inc., New York, USA, Retrieved 1st March 2010


http://books.google.co.uk/books?id=MK1brjp6gaEC&pg=PA136&lpg=PA136&dq=pathophysiology+of+traumatic+tympanic+perforation&source=bl&ots=6AY

Roeser, R.J., Downs, M.P., 2004, Auditory disorders in school children, 4th end., Thieme Medical Publishers Inc, New York, USA, pg 82, Retrieved 1st March 2010


http://books.google.co.uk/books?id=6jRYWYSg29MC&pg=PA82&lpg=PA82&dq=pathophysiology+of+traumatic+tympanic+perforation&source=bl&ots=Goi

Greenburg, M.L., Hendrickson, R.G., Silverberg, M., Campbell, C.J., Morocco, A.P., Salvaggio, C.A., Spencer, M.T., 2005, Greenburg’s text-atlas of Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia. USA, Retrieved 1st March 2010 from: http://www.ksoem.org/upload/data/1012990110.pdf http://books.google.co.uk/books?id=tjZttRRH8H8C&pg=PA146&dq=infection+of+tr

Glasscock, M.E. & Gulya, A.J., 2003, Glasscock-Shambaugh surgery of the ear, BC Decker Inc., Ontario, Canada, pg 364, Retrieved 1st March 2010 from: http://books.google.co.uk/books?id=IvYbOyS6_i0C&printsec=frontcover&dq=Glasscock-Shambaugh+surgery+of+the+ear&source=bl&ots=IDD6P01I-

Howard, Matthew, L. (2009) Middle Ear, Tympanic Membrane, Perforations, California, medicine from: http://emedicine.medscape.com/article/858684

Naumann H.H., Helms J., Jahrsdoerfer R. (1998), Head and neck surgery, Volume 2, Thieme Medical Publishers Inc., New York, USARetrived 03.03.2010 from: http://books.google.co.uk/books?id=MK1brjp6gaEC&pg=PA136&dq=traumatic+perforation+of+tympanic+membrane&cd=6#v=onepage&q=traumatic%20per

(Kyoo Sang Kim Tae Jung 1999)


:-fromhttp://www.ksoem.org/upload/data/1012990110.pdf

Legget, 2010 (Basic Path physiology slides)


Hearing (its physiology and path physiology) by (Aage R. Moller)
Stanley A. Gelfand Hearing (an introduction to psychological and physiological acoustics)

Milchard, A, 2009 lectures on BHA Module :-1st semestre lectures, plus BSA procedure



Saunders, M, 2003, Other conditions of TM perforation, Retrieved 1st May 2010 from: http://www.bris.ac.uk/Depts/ENT/otoscopy_tutorial.htm

Wolters Kluwer Updated 7 April 2010, Micromedex Updated 4 May 2010, Cerner Multum from: - http://www.drugs.com/cg/tympanic-membrane-perforation-inpatient-care.html


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