A tympanic membrane perforation, or ruptured eardrum is a hole in the eardrum that separates the ear canal from the middle ear.
How do you get a hole in the eardrum?
Eardrum perforations can occur as a result of trauma, infection, cholesteatoma (destructive skin cyst), or from prior ear tubes.
Q-tip Trauma
Q-tip injuries are a common cause of a traumatic ear drum perforation. While often used to extract earwax, if not careful they can cause damage to the eardrum and potentially worse, the middle ear bones. For this reason, q-tips are not advised to use for cerumen removal. Instead, earwax removal drops and removal with a curette under a microscope is advised. Barotrauma, or sudden changes in air pressure can also cause an eardrum perforation. Scuba diving is a common activity that leads to this.
Ear Infections
Acute otitis media can cause a perforation and ear drainage. This should be treated with antibiotic ear drops and will often heal in 48 hours.
Cholesteatoma
Cholesteatoma is a benign skin cyst that grows in the middle ear. However, It can be destructive and cause a hole in the eardrum and degrade the middle ear ossicles. This universally will require surgery. Refer to section on cholesteatoma for more information.
Retained Ear Tubes
Persistent holes from prior ear tubes can occur a small percentage of the time. Usually if an ear tube hasn’t fallen out in 3 years, we would recommend removal in repair, however if this hasn’t been detected the perforation may not always heal on its own.
How are eardrum perforations repaired?
Plug or Patch
The technique to repair a tympanic membrane perforation depends on the size of the hole. Small perforations 10% or less can often be repair with a Gelfoam® “plug,” fat graft, or paper patch. Dr. Baktha prefers to use a Gelfoam® plug technique. This procedure is performed under mask sedation (same as ear tube placement) and a small rim of skin on the inner edge of the perforation is removed. This stimulates the regrowth of cells on the eardrum. A small piece of dissolvable Gelfoam® is then placed in the hole as a plug and then the ear canal is filled with Bacitracin ointment. Patients are then requested to follow up in 4 weeks.
Tympanoplasty
Larger perforations, often greater than 10% will likely require a formal tympanoplasty. This is a longer surgery where the entire existing eardrum is raised, a graft is placed underneath, and the eardrum laid back down. The graft acts like a scaffold for the eardrum to heal on its own. Traditionally, temporalis fascia is used as a graft, which is located below the skin behind the ear. The surgery requires a hidden incision behind the ear.
Endoscopic Tympanoplasty
Minimally invasive tympanoplasty, or endoscopic tympanoplasties, can also be performed completely through the ear canal and avoid a behind the ear incision. In this case, a synthetic graft can be used to repair the eardrum. Discuss with Dr. Baktha if your child would be a good candidate for this procedure depending on the size and location of the perforation.
Postoperative Instructions for Tympanoplasty
If your child undergoes a standard tympanoplasty, there will be an incision behind the ear. Following surgery there will be cotton ball in the ear canal, white gauze over the incision and a Velcro wrap around the head covering the ear. This wrap, gauze and cotton ball can be removed in 24 hours. You may elect to use the wrap at nighttime to protect the incision for a few days. It is important to keep the incision dry for 48 hours and then you may wash hair. No water in the ear canal for 4 weeks. You may use a cotton ball with Vaseline on it as an earplug to protect the ear during showers or baths. Dr. Baktha also recommends no strenuous activity for 2 weeks, but your child may go back to school in 3-5 days if he/she feels well.
Common postoperative side effects include pain, nausea, dizziness, and muffled hearing. Sleeping with the head of bed elevated is recommended.
Pain is typically short lived and can often be alleviated with Tylenol and ibuprofen. Healing of the graft can take several weeks and sometimes months. Your first post-op appointment will be one week after surgery for an incision check. Following this, you will be instructed to start antibiotic drops in the ear canal for three weeks until your second appointment where the ear canal will usually be cleaned out. Only after the eardrum is considered dry will a hearing test be obtained.
Endoscopic tympanoplasties require much less post-operative care because there is no skin incision to care for. The ear canal still needs to be protected from water for 4 weeks. Your first appointment will be 3-4 weeks after surgery to evaluate the healing process.