Inner Ear Injuries (Tympanic Membrane Perforation)

By admin On Sep 22, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Rochelle M. Nolte

John Hariadi

Basics

Description

Blunt trauma (slap to the ear)
Penetrating trauma (Q-tip)
Rapid pressure change (diving, flying)
Extreme noise (blast)
Lightning
Spontaneous perforation of acute otitis media
Acute necrotic myringitis

Epidemiology

Incidence

Incidence in general population has not been studied.
A study found that 3% of children with ventilation tubes had tympanic membrane perforations.

Etiology

Infection (such as acute otitis media) is the principal cause of tympanic membrane perforations.
Ear canal infections rarely cause perforations.
Presence of perforation renders ear more susceptible to infection if water enters the canal.
Perforation therefore is an absolute contraindication to irrigation for cerumen removal.

Diagnosis

Direct visualization of tympanic membrane with otoscope
Test hearing in both ears.
Note any nystagmus with changes of position or pressure on the tragus occluding the canal (fistula sign).

Physical Exam

Ear pain (mild)
Decreased hearing (partial)
Severe pain or complete hearing loss in the affected ear suggests additional injuries.
Purulent or bloody discharge from ear canal
Tinnitus
Vertigo
Otorrhea

Diagnostic Tests & Interpretation

Insufflation via pneumatic otoscope:
- Will not cause the perforated tympanic membrane to move normally
- Holding pressure for 15 sec (the fistula test) may cause nystagmus or vertigo if the pressure is transmitted through the middle ear and into a labyrinthine fistula.
Weber test (tuning fork on midline bone):
- Sound should be equal or louder in the injured ear, consistent with decreased conduction.
- Sound localizing to the opposite side of injury indicates possible otic nerve injury.
Rinne test: Usually normal (air conduction detected after bone conduction fades) or shows a small conductive loss (1)

Imaging

Radiography and MRI are of no value unless the clinical picture suggests ossicular destruction and/or cholesteatoma.
Asymptomatic perforations, especially if hearing is near normal, require no imaging studies (1).

Differential Diagnosis

Temporal bone fracture
Serous otitis media
Suppurative otitis media
Otitis externa
Cerumen impaction
Barotrauma
Acoustic trauma
Foreign body
Child abuse

Treatment

ED Treatment

Medical treatment for perforations is directed at controlling otorrhea.
Clean debris from the ear canal.
Prescribe antibiotics if there is evidence of infection.
Acute otitis media with tympanic membrane perforation should be treated with an oral antibiotic (2)[A].
Oral antibiotic choices (administered for 7–10 days):
- Amoxicillin
- Trimethoprim-sulfamethoxazole
- Cefixime
- Augmentin

P.331

Prophylactic antibiotics not indicated
Use topical antibiotics with low acidity/ototoxicity, such as ofloxacin or ciprofloxacin otic, in combination with oral systemic antibiotics.
Topical quinolones (±steroids) are the best treatment for chronic suppurative otitis media (2)[A].
Analgesics if needed for pain
Do not prescribe topical ototoxic eardrops such as gentamicin, neomycin sulfate, or tobramycin.
Arrange ENT follow-up.
- After detailed examination and formal audiometric tests, most otolaryngologists follow the perforation with monthly examinations.
- Operative repair reserved for the 10–20% that do not heal spontaneously.
Provide detailed discharge instructions.
Occlude the ear canal with cotton coated in petroleum jelly or antibiotic ointment when showering to prevent entry of water into the middle ear, which can be painful.
Swim only with fitted earplugs.
Avoid forceful blowing of the nose.
Expected outcome:
- Most perforations heal spontaneously over a few months (68% within 1 mo, 94% within 3 mos).
- A few require operative repair such as a collagen foam splint or a flap from the canal wall.
- Perforations caused by molten metal or electrical burns are less likely to heal spontaneously.
- Forceful entry of water, as in a water skiing accident, is more likely to lead to infection.
- Complications include infection, dislocation of ossicles, perilymph leak, and cholesteatoma.

Medication

Amoxicillin: 250–500 mg (children: 20–40 mg/kg/24 hr) PO t.i.d.
Trimethoprim-sulfamethoxazole (Bactrim DS): 1 tablet (children: 6–12 mg/kg/24 hr) PO b.i.d.
Cefixime: 400 mg (children: 8 mg/kg/24 hr) daily
Augmentin: 250–500 mg (children: 20–40 mg/kg/24 hr) PO t.i.d.
Ofloxacin otic topical solution 0.3%: 10 drops in affected ear b.i.d. × 14 days
Ciprofloxacin 0.3% and dexamethasone 0.1% otic solution (Ciprodex): 4 drops in affected ear b.i.d. × 7 days (2)

Surgery/Other Procedures

Office procedures such as paper patch method (67% success) and fat plug (87% success)
Surgical tympanoplasty under local or general anesthesia (90–95% success) (3)

In-Patient Considerations

Initial Stabilization

Initial stabilization: Airway, breathing, and circulation (ABCs of trauma care)
Immobilize cervical spine, and investigate for intracranial injury when indicated.

Admission Criteria

Associated injuries requiring admission
Severe vertigo impairing ambulation

References

1. Howard ML, et al. Middle ear, tympanic membrane, perforations. eMedicine update 25 September 2009.

2. Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009;79:650, 654.

3. Dursun E, Dogru S, Gungor A, et al. Comparison of paper-patch, fat, and perichondrium myringoplasty in repair of small tympanic membrane perforations. Otolaryngol Head Neck Surg. 2008;138:353–356.

Additional Reading

Gladstone HB, Jackler RK, Varav K. Tympanic membrane wound healing. An overview. Otolaryngol Clin North Am. 1995;28:913–932.

Golz A, Netzer A, Joachims HZ, et al. Ventilation tubes and persisting tympanic membrane perforations. Otolaryngol Head Neck Surg. 1999;120:524–527.

Codes

ICD9

382.01 Acute suppurative otitis media with spontaneous rupture of eardrum
384.20 Perforation of tympanic membrane, unspecified
872.61 Open wound of ear drum, uncomplicated