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Summary Table

Feature	Detail
Risk Factors	Recurrent acute otitis media (AOM), chronic otitis media, barotrauma (diving, flying), blast injury, direct trauma (cotton swabs, foreign bodies), previous tympanostomy tubes
Etiology	Infectious (AOM with rupture), traumatic (penetrating or pressure-related), iatrogenic (post-tube extrusion)
Patient Presentation	Sudden ear pain followed by relief (if infectious), hearing loss (conductive), otorrhea (bloody or purulent), sensation of ear fullness, tinnitus
Classic Physical Exam	Visible defect in the tympanic membrane (TM) on otoscopy; may see purulent drainage in the canal; Weber lateralizes to the affected ear; Rinne shows bone conduction greater than air conduction on the affected side
Key Diagnostic Results	Otoscopic visualization of the defect is diagnostic; audiometry shows conductive hearing loss; tympanometry shows large volume or flat tracing
Management	Most perforations heal spontaneously within weeks; keep ear dry; antibiotic otic drops (ofloxacin) if infection present; surgical repair (tympanoplasty) for persistent perforation beyond 3 months
Keywords	"Sudden relief of ear pain," "drainage from the ear after ear infection," "visible hole in the eardrum," "conductive hearing loss," "Weber lateralizes to affected ear"

1. Pathophysiology

The tympanic membrane is a thin, tri-layered structure (outer squamous epithelium, middle fibrous layer, inner mucosal epithelium) that separates the external auditory canal from the middle ear. It plays two roles: sound transmission via vibration and barrier protection of the middle ear from external pathogens and debris.

Perforation occurs when mechanical stress exceeds the tensile strength of the membrane. In infectious perforation, purulent fluid accumulates in the middle ear during AOM, generating increasing pressure against the TM. When this pressure exceeds the membrane's tolerance, it ruptures. This is why the classic vignette describes a child with severe otalgia from AOM who suddenly experiences pain relief followed by otorrhea. The pressure has been released.

In traumatic perforation, direct penetration (cotton swab, foreign body) or sudden pressure differentials (slap to the ear, diving barotrauma, blast injury) physically tear the membrane. Barotrauma occurs because the eustachian tube fails to equalize middle ear pressure rapidly enough during descent, creating a pressure gradient that deforms and ultimately ruptures the TM.

The resulting conductive hearing loss is directly proportional to the size and location of the perforation. A larger defect reduces the effective vibrating surface area of the TM, decreasing sound energy transfer to the ossicular chain. Posterior perforations tend to cause greater hearing loss because they disrupt the round window baffle effect, which normally creates a phase difference between oval and round window stimulation that is essential for efficient cochlear fluid movement.

An open perforation also eliminates the middle ear's protected environment, allowing bacteria and water from the external canal to enter. This predisposes to chronic suppurative otitis media (CSOM) if the perforation persists.

2. Classification and Clinical Manifestation

Classification	Basis	Features
By Etiology
Infectious	Secondary to AOM	Preceded by fever, otalgia; purulent otorrhea after rupture; often in children
Traumatic	Direct or pressure injury	Sudden onset after identifiable event; bloody otorrhea; pain at time of injury
Iatrogenic	Post-tympanostomy tube	Residual perforation after tube extrusion; usually small and anterior-inferior
By Location
Central (pars tensa)	Perforation within the fibrous annulus	More common; better prognosis for spontaneous healing; lower complication risk
Marginal	Extends to the annulus edge	Higher risk of cholesteatoma formation due to epithelial migration into the middle ear
Attic (pars flaccida)	Superior portion of TM	Strongly associated with cholesteatoma; requires closer surveillance
By Size
Small	Less than 25% of TM area	High rate of spontaneous closure
Medium	25 to 50%	Variable healing; may require intervention
Large/Subtotal	Greater than 50%	Low spontaneous closure rate; typically requires tympanoplasty

Clinical Feature	Infectious Perforation	Traumatic Perforation
Pain pattern	Severe then sudden relief	Acute at moment of injury, then subsides
Otorrhea	Purulent or mucopurulent	Bloody, then serous
Hearing loss	Conductive, mild to moderate	Conductive; may have sensorineural component if blast/barotrauma
Vertigo	Uncommon	May occur with inner ear concussion (blast)
Associated findings	Preceding URI symptoms, fever	History of trauma, diving, or explosion

3. Diagnostic Workup

Test	Role	Expected Finding
Otoscopy	Best initial test and often sufficient for diagnosis	Direct visualization of TM defect; note size, location, margins, and presence of drainage
Pneumatic otoscopy	Assess TM mobility	Decreased or absent mobility on the affected side
Tuning fork tests	Bedside hearing assessment	Weber lateralizes to affected ear; Rinne: bone conduction > air conduction (negative Rinne) on affected side
Audiometry	Quantify hearing loss	Conductive hearing loss pattern; air-bone gap present
Tympanometry	Confirm perforation	Large ear canal volume (open system); flat curve
CT temporal bone	Only if complication suspected	Indicated if cholesteatoma, ossicular disruption, or temporal bone fracture is suspected

Otoscopy is the best initial test and is usually all that is needed. The examiner directly visualizes the perforation, its size, and its location relative to the annulus. Location matters because marginal and attic perforations carry a higher risk of cholesteatoma and may warrant more aggressive follow-up.

Tuning fork testing is a classic exam question. In a conductive hearing loss from TM perforation, the Weber test lateralizes to the affected ear because ambient noise no longer masks bone-conducted sound on that side. The Rinne test on the affected ear shows bone conduction heard longer than air conduction. This pattern distinguishes conductive from sensorineural loss, which is a frequent testing point.

Audiometry is ordered when hearing loss is a concern or when surgical planning is needed. The hallmark finding is an air-bone gap, meaning bone conduction thresholds are normal but air conduction thresholds are elevated.

Tympanometry will show a large equivalent ear canal volume because the tympanometer measures a combined space of the canal plus the middle ear through the open perforation. This is distinct from a normal ear where the intact TM creates a smaller measured volume.

CT imaging is not routinely needed. Reserve it for cases where you suspect complications: cholesteatoma (foul-smelling discharge, marginal perforation), ossicular chain disruption (significant conductive loss disproportionate to perforation size), or temporal bone fracture (post-trauma with facial nerve palsy or hemotympanum).

4. Management and Treatment

Scenario	Management	Details
Uncomplicated perforation (dry)	Observation, ear precautions	Keep ear dry (cotton ball with petroleum jelly during bathing); avoid swimming; follow up in 4 to 6 weeks
Infected perforation / active otorrhea	Topical antibiotic drops	Ofloxacin 0.3% otic, 5 drops to affected ear twice daily for 10 days; avoid aminoglycoside drops (ototoxic through open perforation)
AOM with perforation	Topical plus oral antibiotics	Ofloxacin otic drops plus amoxicillin 80 to 90 mg/kg/day divided twice daily for 10 days (pediatric); or amoxicillin 500 mg three times daily for 7 to 10 days (adult)
Persistent perforation (>3 months)	Surgical referral	Tympanoplasty (paper patch for small defects; formal grafting for larger ones)
Traumatic with suspected ossicular injury	ENT referral	Audiometric evaluation plus CT if conductive loss exceeds what perforation size would explain
Cholesteatoma suspected	Urgent ENT referral	Marginal or attic perforation with foul discharge or granulation tissue requires surgical exploration

Acute management centers on preventing secondary infection and allowing spontaneous healing. The single most tested point here is avoiding ototoxic drops. When the TM is perforated, topical medications can reach the middle and inner ear. Aminoglycoside-containing drops (neomycin, gentamicin) and alcohol-based preparations are contraindicated because they risk sensorineural hearing loss and vestibular damage. The safe choice is fluoroquinolone otic drops(ofloxacin or ciprofloxacin), which are non-ototoxic.

For water precautions, patients must be instructed to prevent water entry into the ear canal during bathing and to avoid swimming until the perforation has closed. Water introduction through an open perforation leads to middle ear contamination and potential CSOM.

Surgical repair is considered when the perforation fails to close after approximately 3 months of observation. Tympanoplasty is the procedure of choice. For small perforations, an office-based paper patch technique may promote closure by providing a scaffold for epithelial migration. For larger defects, formal tympanoplasty with a graft (temporalis fascia or tragal perichondrium) is performed under anesthesia.

The "next best step" logic on exams typically follows this pattern: perforation identified on otoscopy with active drainage, the answer is topical fluoroquinolone drops plus ear precautions. If the question stem describes a dry, stable perforation that has been present for several months with persistent conductive hearing loss, the answer is tympanoplasty referral.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Acute otitis media (without perforation)	Otalgia, fever, decreased hearing in a child	TM is intact, bulging, and erythematous on otoscopy; no otorrhea; no visible defect
Otitis externa	Ear pain and discharge	Pain worsened by tragal pressure or pinna traction; canal is edematous and erythematous; TM is intact when visualized
Chronic suppurative otitis media	Persistent otorrhea with perforation	CSOM is a consequence of unresolved perforation; distinguished by duration greater than 6 weeks of continuous drainage through a perforation
Cholesteatoma	Conductive hearing loss, otorrhea, visible TM abnormality	Foul-smelling discharge, white keratinous mass or retraction pocket in the posterosuperior quadrant or attic; marginal perforation
Hemotympanum	Post-traumatic hearing loss	TM is intact but appears blue or dark red; associated with temporal bone fracture; no visible perforation
Serous otitis media (otitis media with effusion)	Conductive hearing loss, feeling of fullness	TM is intact with visible fluid level or air-fluid interface behind it; TM appears amber or retracted; no perforation
Tympanosclerosis	Abnormal-appearing TM, conductive hearing loss	White calcified plaques on an otherwise intact TM; often an incidental finding in patients with history of recurrent otitis media

6. Traps and High-Yield Pearls

The most common way students lose points on TM perforation questions is by selecting aminoglycoside-containing ear drops for an ear with a known perforation. Many students default to "neomycin/polymyxin B/hydrocortisone" because it is a familiar otic drop, but this combination contains neomycin, which is ototoxic when it contacts middle ear mucosa through the open perforation. The correct answer is always a fluoroquinolone otic preparation.

A second frequent trap involves tuning fork interpretation. Students may confuse the lateralization pattern: in TM perforation (conductive loss), Weber lateralizes to the affected ear, not away from it. This is counterintuitive for many learners who associate the "bad ear" with reduced hearing, but the physics of reduced ambient noise masking on the affected side means bone conduction is perceived as louder there.

Third, watch for the vignette that describes a child with AOM whose pain suddenly resolves and is followed by ear drainage. Students sometimes interpret pain resolution as clinical improvement and select "reassurance." The correct interpretation is that TM rupture has occurred, and the patient now needs topical antibiotic drops to prevent secondary infection.

Finally, any question stem that mentions a marginal or attic perforation with foul-smelling discharge is pointing you toward cholesteatoma, not simple perforation. This requires ENT referral for surgical management, not just observation. The core competency being tested across all these scenarios is the ability to match the clinical finding to its correct next step: safe topical therapy for acute perforation, observation for uncomplicated healing, and surgical referral for persistent or complicated disease.

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