Eardrum Perforation (Perforated or Ruptured Eardrum)

What an eardrum perforation is

The eardrum is a thin, cone-shaped membrane about 1 cm (under half an inch) across. Sound makes it vibrate, and the vibrations pass through three tiny bones to the inner ear. The eardrum also seals the middle ear off from water and germs in the ear canal.

A perforation can be a pinhole or involve most of the drum. Smaller holes cause less hearing loss and heal more easily. Doctors describe:

• Acute perforations: new, from infection or injury. Most heal by themselves.
• Chronic perforations: holes that have lasted more than about 3 months. These rarely close without surgery and are part of chronic otitis media.

The terms perforated, ruptured and burst eardrum all mean the same thing. For the clinical classification, see tympanic membrane perforation.

Symptoms of a perforated eardrum

• Sudden relief of ear pain when an infected eardrum bursts, as pressure behind it is released
• Sharp pain at the moment of an injury
• Discharge from the ear: clear, pus-like or blood-stained
• Muffled hearing in that ear
• Ringing or buzzing (tinnitus)
• Brief dizziness or a spinning sensation, especially after injury
• Hearing air whistle when blowing your nose

Some small perforations cause no symptoms and are found during a routine ear check.

Causes

Middle ear infection

The most common cause, especially in children. In acute otitis media, pus builds up behind the eardrum until it bursts. The pain eases, and discharge appears in the ear canal. These perforations usually heal quickly once the infection settles.

Pressure changes (barotrauma)

The drum can tear if pressure outside the ear changes faster than the Eustachian tube can equalize it: scuba diving, flying with a blocked nose, or a blow to the ear that seals the canal, such as a slap or a fall onto water while water-skiing. See barotrauma.

Direct injury

• cotton swabs, hairpins or pencils pushed too far into the ear
• foreign bodies in the ear, or attempts to remove them
• sparks from welding

Loud blasts

Explosions, fireworks and gunfire close to the ear can rupture the drum and damage the inner ear at the same time.

Head injury

A fracture of the temporal bone at the side of the skull can tear the eardrum and cause bleeding from the ear.

How it is diagnosed

A doctor looks into the ear with an otoscope, a lighted magnifying instrument. A hole is usually easy to see once any discharge is gently cleaned away. They may also:

• puff a little air against the drum (pneumatic otoscopy) to see whether it moves
• use a tuning fork test to check the type of hearing loss
• arrange a hearing test (audiogram), especially after injury or if the hole is large
• refer to an ear, nose and throat (ENT) specialist if there is dizziness, facial weakness, a large hole or signs of skin growth behind the drum (cholesteatoma)

Treatment

Keep the ear dry

This is the single most important step. Water entering through the hole can carry germs into the middle ear.

• Put a cotton ball coated in petroleum jelly in the outer ear when you shower or wash your hair.
• Do not swim until a doctor says the drum has healed.
• Do not use ear drops unless they are prescribed, because some are harmful to the inner ear if they pass through a hole.

Ease pain

Take acetaminophen (paracetamol) or ibuprofen at the label dose. A warm, dry cloth over the ear can help.

Antibiotics

If the perforation came from an infection or the ear is discharging, your doctor may prescribe antibiotic ear drops that are safe for the middle ear, such as ofloxacin or ciprofloxacin, or antibiotics by mouth.

Avoid pressure

Blow your nose gently, one nostril at a time, and avoid flying or diving until healed if possible.

Repair procedures

If the hole has not closed after about 2 to 3 months, or hearing is affected:

• Patch myringoplasty: a small paper or gel patch is placed over a small hole in the clinic to act as a scaffold for new skin.
• Tympanoplasty: surgery under general anesthesia using a graft of the patient's own tissue, usually from behind the ear, to close a larger or chronic perforation. Success rates are high, around 85 to 90%.

Healing time

Hearing usually returns to normal once the drum closes. Your doctor will usually recheck the ear after about 6 weeks.

Complications

• Repeated middle ear infections with discharge, especially after water exposure
• Conductive hearing loss that persists if the hole stays open or the ear bones are damaged
• Cholesteatoma: skin from the ear canal grows into the middle ear through the hole and slowly erodes bone
• Inner ear damage from a blast or deep injury, causing permanent hearing loss or vertigo

Frequently asked questions

Can a perforated eardrum heal on its own?

Yes, in most cases. Around 80 to 90% of small, recent perforations close by themselves within 2 to 8 weeks, as long as the ear is kept dry and infection is treated. Large holes and those that last more than 3 months often need a patch or surgery.

How do I know if my eardrum burst?

Common signs are a sudden easing of ear pain followed by discharge, muffled hearing, ringing in the ear and sometimes brief dizziness. After an injury there may be sharp pain and a little blood. A doctor can confirm it in seconds by looking in the ear with an otoscope.

Is a ruptured eardrum painful?

It hurts at the moment it tears, and the ear may ache for a few days. When an infection causes it, the pain often gets better as the drum bursts, because pressure is released. Ongoing severe pain suggests infection or another problem and should be checked.

Can I fly with a perforated eardrum?

Flying is often less painful with a hole, since pressure equalizes through it. Even so, many doctors advise waiting until it has healed, especially after a recent injury or surgery. Ask your doctor first, and avoid flying with a heavy cold.

Will my hearing come back after a perforated eardrum?

Usually yes. Hearing typically returns to normal once the drum heals. Hearing loss that persists after healing may mean the small ear bones or inner ear were also damaged, which needs a hearing test and ENT review.

Can I shower with a perforated eardrum?

Yes, but protect the ear. Place a cotton ball smeared with petroleum jelly in the outer ear, or use a well-fitting earplug, and avoid getting shampoo or water directly into that ear. Do not swim until your doctor confirms the drum has healed.