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Perforated Tympanic Membrane

Perforated Tympanic Membrane is a topic covered in the 5-Minute Clinical Consult.

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  • The tympanic membrane (TM), or “ear drum,” is a thin, trilaminar barrier that separates the external auditory canal (EAC) from the middle ear. Along with the ossicles of the middle ear, it transmits and amplifies sound vibrations to the cochlea.
  • The TM consists of an outer squamous layer, contiguous with the EAC skin, the middle fibrous layer of both peripheral annular fibers and central radial fibers that provide support, and the inner mucosal layer, contiguous with the middle ear lining.
  • Rupture of the TM can disrupt hearing and can allow pathogens access to the middle ear space from the EAC.
  • Perforations may be classified by location:
    • Central: doesn’t involve the annulus and is more likely to heal spontaneously
    • Marginal: lies in the periphery, involves the annulus; may be associated with cholesteatoma; is less likely to heal and harder to repair
    • Involvement of the malleus decreases chance of healing.
    • Perforations of the posterior superior quadrant overlie the ossicles and the cochlea and are associated with more extensive damage.
    • When a TM perforation heals, the mucosal and squamous layers reepithelialize, but the fibrous layer won’t reform, resulting in a thinner membrane (paradoxically termed “monomeric”).
  • Classification of perforations by etiology:
    • Infectious: acute/chronic suppurative otitis media
    • Traumatic: barotrauma (e.g., diving), acoustic trauma (e.g., explosion), self-inflicted/penetrating (cotton tips)
    • Middle ear mass: cholesteatoma or neoplasm
    • Iatrogenic: persistent perforation after myringotomy tube placement or secondary acquired cholesteatoma
  • The TM possesses the ability for spontaneous closure resulting in formation of a dimeric membrane (outer squamous and inner mucosal). However, if this does not occur, a persistent perforation will result.


Incidence in the general population is unknown because many perforations heal spontaneously.

Genetic susceptibility has been reported for recurrent acute otitis media (AOM) and chronic otitis media with effusion (COME), two of the etiologies of perforations (1).

General Prevention

Preservation of eustachian tube function, avoiding insertion of foreign bodies and objects into the EAC, and prompt treatment of significant infection and inflammation of the ear reduces the chances of perforation.

Risk Factors

  • Eustachian tube dysfunction and inability to equalize middle ear pressures
  • Rapid changes in ambient pressures (air flight or diving)
  • Insertion of objects into ears
  • Head trauma, exposure to explosions

Etiology and Pathophysiology

  • Barotrauma: sudden or large changes in the pressure differential across the TM (such as in air flight, proximity to explosions, or diving underwater)
  • Direct penetration of the TM by a foreign object (e.g., cotton swab)
  • Otitis media: Purulent, inflammatory process leads to ischemia and necrosis of the TM.
  • Inflammation and erosion results from neoplasm, cholesteatoma, and localized infection (e.g., otomycosis).

Commonly Associated Conditions

  • Chronic eustachian tube (craniofacial abnormalities, such as cleft, may predispose)
  • Otitis media with effusion (OME)
  • Recurrent AOM
  • Cholesteatoma
  • Tympanosclerosis
  • Ossicular chain damage (if traumatic perforation)

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Stephens, Mark B., et al., editors. "Perforated Tympanic Membrane." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117239/all/Perforated_Tympanic_Membrane.
Perforated Tympanic Membrane. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117239/all/Perforated_Tympanic_Membrane. Accessed April 24, 2019.
Perforated Tympanic Membrane. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117239/all/Perforated_Tympanic_Membrane
Perforated Tympanic Membrane [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117239/all/Perforated_Tympanic_Membrane.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Perforated Tympanic Membrane ID - 117239 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117239/all/Perforated_Tympanic_Membrane PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -