Tympanic Membrane Perforation: Types, Chronic Holes and Repair

How the eardrum works

The tympanic membrane is a cone-shaped membrane about 9 to 10 mm across and less than 0.1 mm thick. Sound waves vibrate it, and three tiny bones (ossicles) carry those vibrations to the inner ear. It also seals the middle ear from water and bacteria in the ear canal.

It has two parts:

• Pars tensa: the large, taut lower part, where most perforations occur
• Pars flaccida (attic): the small, floppy upper part above the hammer bone

For symptoms and everyday care of a newly burst eardrum, see perforated eardrum. This page covers how doctors classify perforations, why some do not heal, and how they are repaired.

Types of perforation

Doctors also describe size as a percentage of the eardrum, and which quadrant it is in. Larger holes and those near the back cause more hearing loss.

Causes

• Acute otitis media: pressure from pus bursts the eardrum, often relieving pain suddenly. The most common cause in children.
• Chronic otitis media: repeated infection prevents healing and causes recurring discharge (chronic suppurative otitis media).
• Barotrauma: pressure changes from flying, diving or a slap over the ear.
• Direct injury: cotton swabs, hairpins, sticks, or welding sparks.
• Acoustic trauma: explosions or very loud blasts.
• Head injury: especially temporal bone fractures.
• Ear tubes: a small hole sometimes remains after a ventilation tube falls out.

Why some perforations do not heal

Most traumatic and infection-related perforations close within 6 to 8 weeks as the outer skin layer grows across the gap. Healing is less likely with:

• Large, subtotal or marginal perforations
• Ongoing infection or discharge
• Poor eustachian tube function (the tube that equalizes middle ear pressure)
• Skin growing over the edge of the hole into the middle ear
• Burns from hot metal or chemicals
• Previous radiation, diabetes or smoking

A perforation that has not healed after about 3 months is considered chronic.

Diagnosis

1. Otoscopy or ear microscopy: shows the hole's size, location and edges, and whether there is discharge, scarring or white debris suggesting cholesteatoma.
2. Audiogram: measures hearing in each ear. Perforations typically cause a mild to moderate conductive hearing loss. A large gap between bone and air conduction suggests ossicle damage.
3. Tympanometry: measures eardrum movement and middle ear volume. A perforation shows a large volume.
4. Ear swab for culture if discharge persists.
5. CT scan of the temporal bone if cholesteatoma, bone erosion or head trauma is suspected.

Treatment

Waiting for natural healing

For acute perforations:

• Keep water out of the ear: earplugs or cotton balls coated with petroleum jelly when showering, and no swimming until healed.
• Antibiotic ear drops (fluoroquinolones such as ofloxacin or ciprofloxacin are safe with a perforation) if there is infection or discharge. Avoid drops not approved for use with a perforated eardrum, including some containing aminoglycosides.
• Pain relief with acetaminophen (paracetamol) or ibuprofen, following the label dose.
• Recheck at 6 to 8 weeks to confirm closure and hearing.

Repair options

Graft success rates for tympanoplasty are typically reported around 80% to 90% or higher. Recovery takes a few weeks, with water precautions and no flying or heavy straining until the surgeon advises.

Complications

• Persistent conductive hearing loss
• Recurrent ear infections and discharge, especially after water exposure
• Cholesteatoma: skin growing into the middle ear, which can erode bone and needs surgery
• Rarely, inner ear damage causing sensorineural hearing loss, vertigo or tinnitus

Frequently asked questions

What is a tympanic membrane perforation?

It is the medical term for a hole or tear in the eardrum. It can result from middle ear infections, pressure changes, injuries or loud blasts. Most small perforations heal on their own within weeks, while some persist and need repair.

What is the difference between central and marginal perforation?

A central perforation has a rim of eardrum all around it and is usually considered "safe". A marginal perforation reaches the bony edge of the eardrum, allowing skin to grow into the middle ear, which raises the risk of cholesteatoma.

When does a perforated eardrum need surgery?

Surgery is usually considered if the hole has not healed after about 3 months, if it causes troublesome hearing loss or repeated infections, or if cholesteatoma is present. Small holes may be closed with an office patch or fat graft.

How successful is tympanoplasty?

Tympanoplasty closes the eardrum in most people, with reported success rates of roughly 80% to 90% or higher. Hearing often improves, especially when the ossicles are intact. Success is lower with ongoing infection, smoking or poor eustachian tube function.

Can I swim with a tympanic membrane perforation?

Avoid swimming until the eardrum has healed or been repaired, because water can carry bacteria into the middle ear. If you must swim with a chronic perforation, your doctor may advise custom-fitted earplugs and a swim cap.