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Eardrum perforation

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​The eardrum is a small membrane at the end of the ear canal. The eardrum collects the sounds that come into the ear canal. 

These sound waves vibrate the eardrum; the sounds are then transmitted to the bones of hearing (ossicles). The eardrum also protects the middle ear so debris and bacteria do not enter the middle ear.

An eardrum perforation is a hole or opening in an otherwise intact eardrum. The size of the perforation can vary from a small pinpoint opening to a loss of the entire eardrum.

How does a perforation of the eardrum occur?

There are many ways an eardrum perforation can occur. An infection behind the eardrum in the middle ear may cause a rupture of the eardrum. Trauma to the ear may result from an object entering the ear canal and puncturing the eardrum. A traumatic blow to the ear with a cupped hand can rupture the eardrum. Hot welding slag can burn a hole through the eardrum. After a ventilation tube has been extruded or is removed, the opening usually closes; in some cases a permanent opening of the eardrum may occur. Chronic ear problems such as deep retraction pockets and cholesteatoma​​ can weaken and erode the eardrum, resulting in a defect or perforation.

What problems may occur as a result of an eardrum perforation?

Debris, dirty water and bacteria may enter the middle ear through the perforation. This may result in an infection commonly associated with a discharge out of the ear. Most perforations are associated with hearing loss. The degree of hearing loss depends in part on the size of the perforation, the location of the perforation on the eardrum, and whether there is other pathology present in the ear. In some cases, skin can grow around the margins of the perforation, forming a skin cyst (cholesteatoma), in the middle ear and mastoid. However, in many patients with a perforation of the eardrum, the ear remains free of infection and can be safely left without surgical closure of the perforation.

What can be done to repair the perforation?

Some perforations will heal spontaneously without any surgical intervention. In some cases, a paper patch can be placed over the perforation as an office procedure to promote healing. Many times, surgery is required to close the perforation.

What is used to close the perforation?

In most cases, tissue is taken from above the ear and used as graft material. Beneath the skin above the ear is a muscle. The covering over this muscle is called fascia. A piece of fascia is removed through an incision above the ear. This does not produce any changes in the function of this muscle. The tissue (fascia) is laid into the ear and heals as the new eardrum. Some surgeons use other tissue such as vein, perichondrium (covering over cartilage), periosteum (covering over bone), or cadaver tissue.

What surgical approach is used to repair the eardrum?

There are two major approaches to the eardrum: transcanal and postauricular. In the postauricular approach, an incision is made behind the ear. The ear is reflected forward and the eardrum can be visualized. In the transcanal approach, a speculum is placed in the outer opening of the ear canal. The eardrum is visualized by working through the speculum.

What is done to repair the hole in the eardrum?

Once the surgeon has full view of the eardrum, the margins around the perforation are freshened with an instrument. This removes the rim around the perforation producing a raw circumferential edge of the remaining eardrum. Incisions are made in the ear canal skin; part of the ear canal skin, along with any remnant of good eardrum is elevated. The fascia is laid into the ear to cover the perforation on the underneath side of the eardrum. The canal skin is put back in place; the ear canal is packed and a cotton ball applied. The healing process takes about four to six weeks.

Are there any risks with this surgery?

Any surgical procedure carries potential risks. These risks are discussed with the patient and/or family prior to surgery.

  • Hearing loss: There is a slight chance of hearing loss in the inner ear. This loss can be complete and permanent.
  • Dizziness: Some patients experience dizziness that resolves within a day of surgery. It is not likely for dizziness to be a persistent problem.
  • Facial paralysis: The nerve that innervates the muscle of the face courses through the ear. Therefore, there is a slight chance of a facial paralysis. The facial paralysis affects the movement of the facial muscles for closing of the eye, making a smile and raising the forehead. The paralysis could be partial or complete. It may occur immediately after surgery or have a delayed onset. Recovery can be complete or partial.
  • Tinnitus: Tinnitus, or noises in the ear, can occur with surgery, but is an uncommon post-operative problem.
  • Taste abnormalities: A small nerve that innervates some of the taste and salivary function courses through the ear. After ear surgery, some patients experience an abnormal taste in the mouth or some dryness of the mouth. Many times, this problem will improve over time.

It is generally felt that the occurrence of these potential complications is less with surgeons who are well trained in otologic surgery, have experience in performing these surgeries and perform these procedures on a regular basis.

Along with these otologic risks, any surgery carries the risk of anesthesia, bleeding, infection and other more remote operative problems.

Are there any activity restrictions during the post-operative period?

It is important to keep water from entering the ear canal during the healing process. Cotton tip carriers or earplugs should not be placed into the ear, this may disrupt the healing process. The patient should not manipulate the ear even if there is an itching sensation; this may shear the small blood vessels needed for the healing process. The patient should not undergo any heavy physical activity in the post-operative period. Since each case is different, the patient's surgeon should review the specific details regarding post-operative care. The recovery room nurses will go over a printed post-operative instruction sheet before the patient is discharged.

Is the operation performed in all age groups?

Yes, the surgery can be performed in children and adults.

What are the goals of this surgery?

There are two primary goals of surgery to repair the eardrum. First, to close the opening (perforation) in the eardrum. This protects the middle ear from the outside environment by producing an intact eardrum. Second, to maintain, preserve or restore the hearing. The operation is generally successful; but the surgeon can review the unique and specific issues with each patient depending upon the size of the perforation, other ear pathology and other factors that may have an impact on the outcome of the surgery.

Is the procedure done on an outpatient basis?

Yes. Virtually all tympanoplasty surgeries for repair of the eardrum, both for children and adults, are performed on an outpatient basis.

Is this a commonly performed surgery?

A tympanoplasty (repair of the eardrum) is one of the more commonly performed ear surgeries. As with any surgical procedure, each surgeon has their own variations of the technique. There are many factors that affect surgical results, including the amount of disease in the ear, patient healing factors, surgical technique, and the experience of the surgeon.

Types of eardrum perforations​

Perforation at margin of the eardrum

This is a perforation that occurs at the margin of the eardrum - where the eardrum and ear canal come together.

In some cases, skin from the ear canal can grow through the perforation into the middle ear, forming a cholesteatoma.

Central eardrum perforation

A perforation can occur in any location on the eardrum. The size of the perforation varies from a small opening like the one shown, to a total (entire) eardrum perforation.

Attic perforation of the eardrum

This is a perforation in the superior part of the eardrum. This is sometimes referred to as an attic perforation. A perforation in this location may be associated with a deep retraction pocket or cholesteatoma into the mastoid.