Inner Ear Injuries (Tympanic Membrane Perforation)

Ovid: 5-Minute Sports Medicine Consult, The

Inner Ear Injuries (Tympanic Membrane Perforation)
Rochelle M. Nolte
John Hariadi
  • 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
  • Incidence in general population has not been studied.
  • A study found that 3% of children with ventilation tubes had tympanic membrane perforations.
  • 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.
  • 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)
  • 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
  • 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

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