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  • Writer's pictureDr. Koralla Raja Meghanadh

Perforated Eardrum (Ruptured Tympanic Membrane)


A perforated eardrum or a ruptured tympanic membrane is a condition with a tear or a hole in the eardrum. A ruptured ear drum can occur due to various causes and result in hearing loss.

 

Left ear perforation - failed tympanoplasty

Eardrum or Tympanic Membrane and its functions

The eardrum or Tympanic membrane vibrates like a “drum skin” or “drum head” of a drum. The difference is in drums, you hit the drums to generate mechanical waves that convert into sound waves, but in eardrums, the scenario is reversed. The eardrum vibrates for sound waves and converts them into mechanical waves.

 

The eardrum consists of 3 layers.

  1. Skin – outer layer towards the external ear

  2. Fibrous layer – middle layer

  3. Mucous layer - inner layer that lies towards the middle ear

 

This thin membrane is like the outer wall of the middle ear. The middle ear is like a small cubic room where the other sides are bones.

 

For effective hearing, the eardrum concentrates mechanical waves from a larger surface area into a smaller one, roughly 200 square millimeters, into 1 to 2 square millimeters. This concentrated energy is then transmitted through a chain of bones, with the malleus, the first bone in the chain, being part of the eardrum.


A damaged eardrum, including a perforated one, will be unable to convert the sound waves effectively to mechanical waves, resulting in hearing loss.

 

What is a Perforated Eardrum?

A perforated eardrum, or a hole in the ear, is a condition where the eardrum could be ruptured due to various causes like ear infection, traumatic incidents, or accidentally poking it with an external object.

 

The perforation directly affects its function, i.e., the ability to vibrate for sound waves resulting in hearing loss. The hole in the eardrum can also result in complications that result in further damage to the ear.

 

Eardrum Perforation Causes

Several events can trigger or cause perforation in the eardrum.

  1. Blowing the nose

  2. Traveling on a plane

  3. Diving

  4. Traveling in a very fast lift

  5. Going on the mountains at a high speed

  6. Fungal ear infection

  7. Bacterial ear infection

  8. Cleaning the ear with external objects and accidentally damaging the tympanic membrane

  9. Slap on the ear

  10. Loud noises

  11. change in air pressure

  12. Otitis Externa - External ear infection

  13. Otitis Media - Middle ear infection

  14. Tuberculosis

  15. Bullous Myringitis – blisters on the eardrum

 

Any of these factors can initiate a perforation, particularly in the presence of a differential pressure. When the pressure in the middle ear is not equal to environmental air pressure, perforation happens. So, it is important to understand the role of differential pressure.

 

Role of Differential Pressure in Perforation

Eardrum perforation often happens because of differences in pressure between the middle ear and the environment. When the pressure in the middle ear becomes higher than the outer ear or external environment, the eardrum can bulge like a balloon, causing ear pain.


If this pressure gets too high beyond the elasticity of the eardrum, a small hole will be formed, or we can call it a tear in the tympanic membrane or eardrum perforation.


The hole or tear in the tympanic membrane helps equalize the air pressure on both sides of the eardrum and relieves us from the pain.


Several factors contribute to the progression of eardrum perforation due to the differential pressure.

 

  1. Firstly, increased pressure in the middle ear can lead to the compression of blood vessels in the eardrum, along with the spread of bacteria that lie in the structures of the eardrum. This may contribute to the formation of perforation, as bacteria can eat away the eardrum, causing damage and perforation.

  2. Due to the increased pressure in the middle ear, the eardrum experiences pressure that results in the blockage of blood vessels. These vessels, being soft tubes, become completely obstructed under the pressure, leading to a lack of blood supply to the eardrum. Consequently, it not only stops functioning but also dies.

  3. If the pressure in the middle ear is significantly lower than in the outer ear, it can lead to the formation of Cholesteatoma. The continuous negative pressure can damage the fibrous coat of the eardrum, which serves as a protective layer. Without this fibrous coat, the outer skin and inner mucosa become vulnerable to even minimal pressure or forceful nose blowing, potentially resulting in a ruptured eardrum. Surgery is mandatory for cholesteatoma.

Causes of Differential Air Pressure

Generally, any blockage in the air supply to the middle ear will trigger the difference. There are multiple causes, like

  1. Anatomical anomalies - a. thinner Eustachian tubes b. mucosal folds in the middle ear c. Blockage of Isthmus Anticus and Isthmus Posticus

  2. Cold or infection in the nose

  3. Sinusitis

  4. Allergy

  5. Enlarged tissues in the nasopharynx (Eg: Enlarged Adenoids)

 

Tympanic Membrane Perforation Symptoms

A perforation in the eardrum can manifest through various symptoms, like:

  1. Deafness, which can be felt as an Ear Block Sensation or Dullness in Hearing

  2. Ear Pain

  3. Ear Discharge

  4. Tinnitus

  5. Pain Behind the Ear

It's important to note that individuals may not always recognize these symptoms on their own, and in some cases, the condition may be asymptomatic. If there is a suspicion of eardrum perforation, or if any of these symptoms are present, consulting with an ENT doctor is crucial for accurate diagnosis and treatment.

 

Diagnosis

The diagnosis of eardrum perforation involves doing a simple examination of the ear using tools like an otoscope or a headlight.

 

Treatment for Perforated Eardrum

The treatment for perforated eardrums focuses on addressing the root cause, typically linked to middle ear infections or external ear infections, i.e., Otitis Media or Otitis Externa. The primary goal is to correct the underlying issue, and this often involves the administration of antibiotics tailored to the specific type of bacteria or fungus causing the infection.

 

In most cases, if the treatment is initiated early, during the initial three months, there is a good chance of the perforation healing. However, if the perforation is extensive or if the infection persists beyond this period, it may lead to a permanent perforation.

 

Perforation due to Otomycosis, i.e., infections in the external ear due to fungus, are more likely to require surgery than the perforation that is the result of a bacterial infection.

 

Eardrum Rupture Surgery

When is surgery required?

For cases of chronic or permanent perforation, surgical intervention may be necessary to close the eardrum.


What is done in the Procedure?

Reconstruction of the eardrum is done in this surgery.


The procedure entails removing a portion of tissue from the back of the ear, constructing a new eardrum with this material, and allowing the body's natural processes to incorporate it.


This material placed during the procedure acts as a fibrous layer providing a foundation for the skin and mucosa to grow, ultimately resulting in the regeneration of a functional eardrum.

 

Prevention of Perforated Eardrum

Eardrum perforation can be easily

  1. On-time treatment for ear infection

  2. Do not blow your nose, especially when one nostril is blocked

  3. Avoid using oil in your ears. If a fungal infection exists, the fungus can grow rapidly and result in a perforated eardrum.

  4. Avoid using ear drops for ear infections before getting a diagnosis.

  5. Avoid loud noises


Complications of Eardrum Rupture

Eardrum perforation can lead to various issues, primarily centered around the potential spread of infection to adjacent ear structures.

 

When the infection reaches the inner ear, you can experience further hearing loss, tinnitus, nerve weakness, and partial deafness. Additionally, when the infection reaches the balancing organ of the inner ear, giddiness can occur.

 

Moreover, one can get a middle ear and outer ear infection even without a prior infection. One may develop such an infection.

 

How to prevent eardrum perforation complications?

Preventing eardrum perforation and associated complications involves taking certain precautions and adopting some home remedies. Here are some prevention tips:

  1. Use Petroleum Jelly and Cotton Plugs: during the bath, always use a cotton plug smeared with petroleum jelly in your ear to prevent water from entering the ear canal.

  2. Avoid Water Entry: Ensure that water does not enter the ear during activities like bathing or swimming.

  3. Avoid Putting Oil in the Ear: putting oil in the ear can provide a conducive environment for fungal growth in the ear.

  4. No Antibiotic Ear Drops Without Infection: Using ear drops in the absence of infection may introduce bacteria into the middle ear.

  5. Check Throat and Nose for Infections: Regularly check for infections in the throat and nose, as they are connected to the middle ear.

  6. Address Viral Infections: Efficiently treat viral infections such as common cold or sinusitis. as they can serve as potential sources of infection to the middle ear.


Adhering to these prevention tips can significantly reduce the risk of eardrum perforation and associated complications.


Conclusion

To wrap it up, a perforated eardrum can stem from different causes, impacting hearing and overall ear health. Recognizing the role of pressure imbalances and adopting preventive measures is key. If you suspect an issue, consult an ENT doctor promptly. Timely care and simple precautions, like protecting your ears from water and loud noises, are vital in maintaining ear health.


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