ENT

Perforated Eardrum

A tympanic-membrane perforation is a hole caused most often by acute otitis media, direct trauma or pressure change; most heal spontaneously, so keep the ear dry, avoid instrumentation and unprescribed drops, and refer persistent, infected or complicated perforations.

In a nutshell

A perforated eardrum is a hole in the tympanic membrane, most often from acute otitis media or trauma. It causes discharge and conductive hearing loss; most heal within about 2 months. Keep the ear dry, avoid objects and unprescribed drops, treat infection with a clinician-selected regimen, and refer persistent, recurrent, marginal/attic or complicated disease.

Classic presentation

Acute otitis media causes severe earache that settles as bloody-purulent discharge appears, or a cotton-bud/blow/pressure injury causes sudden pain, tinnitus and hearing loss with a visible tympanic-membrane defect.

Key points

Main causes are acute otitis media, direct trauma, loud noise and pressure change.
The expected hearing loss is conductive; vertigo or sensorineural loss suggests inner-ear/temporal-bone injury.
Most acute perforations heal spontaneously within weeks; keep water out and do not instrument the ear.
Do not self-prescribe drops: choose treatment using the BNF, tympanic-membrane status and local ENT/microbiology policy.
Persistent discharge, hearing loss, marginal/attic disease or suspected cholesteatoma needs ENT review and possible repair.

First-line investigation

Otoscopy to confirm site, size, discharge and associated disease, with audiometry when hearing loss is significant, persistent, asymmetric or traumatic.

Management

Identify deeper injury

Urgent ENT/emergency assessment is needed for penetrating or severe head injury, facial weakness, vertigo, severe imbalance, sudden hearing loss or a sensorineural component.^1,3,7

Keep the ear dry and protected

Keep water out, avoid swimming, cotton buds and forceful nose blowing, and use appropriate analgesia; most acute perforations heal without intervention.^1,2,6

Treat infection safely

Use a clinician-selected antimicrobial plan if infection is present; do not self-prescribe drops, and check ototoxicity, the BNF and local ENT/microbiology policy whenever the drum is perforated.^1,4,5,6

Recheck healing and hearing

Review persistent pain, discharge or hearing loss and reassess the drum; most heal within about 2 months, but non-healing or recurrent disease needs ENT review.^1,2

Refer complicated or persistent disease

ENT may use microscopy, audiometry, imaging and specialist topical treatment; myringoplasty/tympanoplasty can be discussed for a persistent perforation or recurrent discharge/hearing problem.^1,4,2

Exam traps

Vertigo or sensorineural loss after trauma is not a simple perforation until deeper injury is excluded.
Do not irrigate, swim or put cotton buds into an open middle ear.
Routine ototoxic ear drops are unsafe; any exception requires clinician/specialist justification and local policy.
Chronic foul discharge with attic or marginal disease suggests cholesteatoma.
A persistent perforation may need myringoplasty/tympanoplasty even if the acute pain has settled.

Illustrations

Large tympanic-membrane perforation on otoscopyOtoscopy showing a large central tympanic-membrane perforation with middle-ear structures visible through the defect.Didier Descouens, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.