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Condition: Traumatic tympanic perforation Definition: Perforation of the tympanic membrane refers to either a “partial” or total hole in the tympanic membrane (T.M.) (Ibekwe et. al, 2007). A perforation of the tympanic membrane produces a conductive hearing loss in the affected ear (Berger G). Path physiology: Perforations may spontaneously heal with time (Gelfand, 2009) but in some cases of traumatic perforation a tympanoplasty may be performed to reduce the risk of infection (Omadasun, 2002 & Merwin and Boies, 1980). Larger perforations are usually associated with chronic infections of the middle ear space and these may be more likely to require surgical intervention (Gelfand, 2009). Sub categories include 1) Marginal, 2) Central and 3) Attic perforations. Marginal perforations involve the fibrous annulus, although central perforations do not involve the fibrous annulus (Oghalai, 2006). Perforations classed as an ‘attic perforation’ usually involve the Pars flaccid (Gelfand, 2009). Central perforation seem to be most common type (Legget, 2010) and one of the most common reasons for traumatic perforations are from “Overpressure”, such as those caused by a hit. (Afolabi et. al, 2009) Traumatic perforations are usually caused by a sudden force, change of pressure or object that is substantial enough to create a hole in the eardrum (Greenburg, et. al, 2005). Common causes include: accidental or purposeful insertion of an object into the external auditory meatus (EAM) such as a pencil or sewing needle (Oghalai, 2006) Sudden force such as a jet of water (Shanks & Shohet, 2009), a slap to the nose (Amadasun, 2002), or as a result of an explosion (Kronenberg et.al, 1993) Pressure changes between the environment and ear; barotruama, Ear syringing or suctioning (Amadasun, Thermal injuries as a result of sparks from industrial processes such as welding (Kyoo Sang Kim Tae Jung 1999) Surgical removal of foreign bodies Potential infection of the middle ear (Amadasun, 2002) -purulent acute otitis media with tympanic membrane perforation -chronic otitis media with tympanic membrane perforation(Berger G.) Trauma -to the tympanic membrane -to the temporal bone(Berger G.) Domestic violence or assault where the ear or face receives a sudden force (Afolabi, 2009) Perforations due to burns can often become infected and the patient may experience otorrhea. Trauma to the tympanic membrane and the middle ear can be caused by overpressure slap on the ear, fight, assault and road traffic injury, Thermal or caustic burns, penetration by instruments and barotraumas. The thermal injury was caused by metal spark perforating the tympanic Tae Jung 1999). A perforation of the tympanic membrane results in a conductive hearing loss. This occurs because the there is a reduced surface area over which the tympanic membrane can vibrate. (Gelfand, 2009, pg 171). Consequently the area to ratio difference between the tympanic membrane and oval window is also reduced. Whereas a fully intact membrane would give an approximate pressure gain at the oval window of times twenty, a perforated eardrum would not provide the same pressure gain. This means a significant amount of the impedance matching property of the middle ear is reduced. As the malleus is attached to the tympanic membrane by the fibrous layer (Howard, 2009); a perforation can also affect this attachment, reducing the vibrations transmitted by the ossicular chain (Gelfand, 2009 pp171). A healed perforation can form a neomembrane which is a thin membrane made up of mucosal and ‘squamous epithelia layers’ with no fibrous layer present (Howard, 2009). These neomembranes are often mistaken for perforations because the membrane is so thin or because they have retracted in to the middle ear (Howard, 2009). They should not be confused with perforations. Symptoms: Symptoms vary between individuals and depend on the size and location of the perforation (Gelfand, 2009). Tinnitus Sudden hearing loss (Afolabi et. al, 2009) Otalgia (ear pain) Bleeding from the ears Epidemiology: Perforations can affect any one of any age and this is unpredictable due to the sudden nature of the perforation. However it is more common in certain groups of people. Traumatic perforation of the tympanic membrane has been reported to occur in up to 36.5% of those injured by terrorist attacks and up to 63.2% of casualties following an explosion (Cooper, et. al, 1983, cited in Kristensen, 1992) Estimates of the prevalence vary with estimates ranging from 1.4 to 8.6 per 100,000 people (Griffin, 1979 & Kristensen et. al, 1989, cited in Kristensen, 1992) Another central location is the head and neck, which is the site of up to 50% of abusive injuries. This could cause high or low perforation depends on how bad is the injury. Thermal burns causing perforation are more prevalent in occupations such as welders (Naumann et.al, 1998, pp136) Perforations as a result of a sudden blast or explosion are more common in times of unrest or war (Kronenburg et. al, 1993) Those caused by a sudden force such as a slap may be associated with assault (Glasscock, M.E. & Gulya, A.J., 2003) Management: As up to 94% of perforations heal naturally (Berger, G, & Gelfand, 2009) medical intervention is not usually necessary. In these situations monitoring of the perforation is usually sufficient. However it is necessary in some cases to intervene and options include: Using a specialised plug with a topical antibiotic to prevent an infection (Omadasun, 2002) Ensuring the ear is kept dry to discourage bacteria from growing in the warm and moist conditions (Chukuezi, A.B. & Nwosu, J.N, 2009) Surgery such as a tympanoplasty or myringoplasty for larger perforations (Gelfand, 2009). Both involve using a tissue graft to repair the perforation. There is some evidence that treating tympanic membrane perforations surgically may resolve symptoms, improve the patients hearing, and may prevent further ear infections (Moller, A.R., 2006) CONDITION: Traumatic (tympanic) perforation in left ear Otoscopy Notes: - The right tympanic membrane appeared to be normal under otoscopy. The left ear was noted to have a central perforation in the inferior posterior part of the tympanic membrane beside the Umbo. Otoscopy can also be useful in order to reveal the cause of the perforation, traumatic perforations usually have sharp ragged edges and blood can often be see in the EAM or middle ear (Naumann et al 1998, pp136). Sub categories of TM perforation include 1) Marginal, 2) Central and 3) Sub total central - This term is used by some ENT surgeons in the UK and refers to a very large central perforation surrounding one side of the umbo (Legget, 2010) (Basic Pathophysiology slides). Central perforation seems to be most common. Tuning forks (non central perforation) Weber: Lateralises to the left Rinne: Right ear positive Left ear negative Notes: The Weber test shows lateralisation to the left side with conductive hearing loss. The Rinne result for the right ear indicates that the sound was heard better by air conduction than bone conduction. The negative left Rinne shows that the sound was perceived to be better via bone conduction than air conduction. Both tests results suggest CHL on the Left. Pure tone audiometry and uncomfortable loudness levels (non central LEFT -10 0 0 10 10 20 20 30 30 Hearing level (dB) Hearing level (dB) RIGHT -10 40 50 60 70 80 40 50 60 70 80 90 90 100 100 110 110 120 120 130 130 140 140 125 250 500 1000 2000 Frequency (Hz) 4000 8000 125 250 500 1000 2000 Frequency (Hz) 4000 8000 perforation) Notes: PTA results indicate a unilateral mild-moderate sloping mixed hearing loss; masked bone conduction was required at 500Hz, 1000Hz, 2000Hz and 4000Hz in the left ear, due to the presence of an air-bone gap of more than 10dB. A large air bone gap in the suspect ear could indicate the incidence of ossicular chain disruption caused by the perforation. Profound sensorineural hearing loss in the suspect ear could indicate labyrinthin Tympanometry ( non central perforation) Notes: A 226Hz probe was used at all times using the diagnostic mode at a rate of 50da pa per second. Flat trace for left ear is the expected result for a left TM perforation. The abnormally high ear canal volume result (above 2.0ml) for the left ear supports the otoscopy findings that show a small central inferior posterior perforation. This is as the volume of the middle ear cavity has also been recorded. The right ear has results within the normal range, of between -50 and +50 daPa for middle ear pressure and between 0.3-1.6 ml for middle ear compliance. Acoustic reflexes (central perforation) Right Threshold Stimulus ear Left Contra lateral Ipsilateral Stimulus Ipsilateral Contra lateral > 100 dB 80 500Hz > 100 dB 80 > 100 dB 85 1000Hz > 100 dB 90 > 100 dB 90 2000 Hz > 100 dB 85 > 100 dB 85 4000 Hz > 100 dB 80 > 100 dB 65 BB Noise > 100 dB 70 Notes: Reflexes could not be obtained for the ipsilateral left reflex or the contra lateral right reflex because we stop increasing the intensity of the stimulus if there is no result for 100dBHL . The reason for the absences is because of the ‘probe ear and stimulus ear principles’ (Katz et. Al, 2009). These state that if there is a conductive hearing loss in the probe ear, then the acoustic reflex of that middle ear will be absent . Results from the contra lateral left and ipsilateral right reflexes are within the normal threshold range of 75-90 db for pure tones and 50-75db for broad band noise. Differential diagnosis: Left facial nerve paralysis results might be almost identical to these expected results. Acoustic reflex results are not sufficient to diagnose TM perforations, however when combined with the other test results, particularly otoscopy results, correct diagnosis of TM perforation should be straightforward. Otoacoustic emissions N/A N/A Notes: The detection of distortion-product otoacoustic emissions depends on the viability of the ear's conduction apparatus. However, tympanic membrane perforations and other conductive disorders have not been fully investigated with regard to the examination. References : References: Berger G. Nature of spontaneous tympanic membrane perforation in acute otitis media in children. J Laryngol Otol. 1989 Dec;103(12):1150-3. Amadasun, J.E.O., ‘An observational study of the management of traumatic tympanic membrane perforations’, The Journal of Laryngology & Otology, March 2002, Vol. 116, pp 181-184 Oghalai, J.S., 2006, ‘Tympanic membrane, middle ear and mastoid disease’, Baylor College of Medicine, Otolaryngology- head and neck surgery, Retrieved 28th February 2010 form: http://www.bcm.edu/oto/jsolab/tm_me_mastoid/tympanicmembrane.htm Shanks, J & Shohet, J, 2009, ‘Tympanometry in clinical practice’, in J Katz, L Medwetsky, R Burkard & L Hood, Handbook of Clinical Audiology, 6th edn., Lippincott Williams & Wilkins, Maryland, USA, pp 181-182 Gelfand, S.A., 2009, Essentials of Audiology, Thieme Medical Publishers Inc., New York, USA, pp 172 Kronenberg, J, Ben-Shoshan, J & Wolf, M, ‘Perforated tympanic membrane after blast injury’, The American Journal of Otology, 1993 Vol. 14, no. 1, pp 92- 94 Kristensen, S, ‘Spontaneous healing of traumatic tympanic perforation in man: A century of experience’, The Journal of Laryngology and Otology, Vol. 106, 1992, pp 1037-1050, retrieved 1st March 2010 from: http://journals.cambridge.org/download.php?file=%2FJLO%2FJLO106_12%2 FS0022215100121723a.pdf&code=576126299d8f703f74f024857fd4885c Ibekwe, T.S., Ijaduola, G.T.A., Nwaorgu, O.G.B., ‘Tympanic perforation among adults in West Africa’, Otology & Neurotology, 2008 Vol. 28, pp 348352 Afolabi, O.A., Aremu, S.K., Alabi, B.S. & Segun-Busari, S, ‘Traumatic tympanic membrane perforation: An aetiological profile’, BMC Research Notes 2009, retrieved 28th February 2010 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785833/pdf/1756-0500-2232.pdf Chukuezi, A.B. & Nwosu, J.N., ‘An unusual cause of acute tympanic membrane perforation: a case report’, International Journal of Medicine and Medical Sciences, Vol 1(4), 2009, pp 97-98, retrieved 28th February 2010 from: http://www.academicjournals.org/ijmms/PDF/pdf2009/Apr/Chukuezi%20and% 20Nwosu.pdf Naumann, H.H., Helms, J, Herberhold, C, Jahrsdoerfer, R.A., Kastenbauer, E.R., Panje, W.R. & Tardy Jnr., M.E., 1996, Head and neck surgery: Volume 2: the Ear, Thieme Medical Publishers Inc., New York, USA, Roeser, R.J., Downs, M.P., 2004, Auditory disorders in school children, 4th end., Thieme Medical Publishers Inc, New York, USA, pg 82 Greenburg, M.L., Hendrickson, R.G., Silverberg, M., Campbell, C.J., Morocco, A.P., Salvaggio, C.A., Spencer, M.T., 2005, Greenburg’s text-atlas of Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia. USA Glasscock, M.E. & Gulya, A.J., 2003, Glasscock-Shambaugh surgery of the ear, BC Decker Inc., Ontario, Canada, pg 364 Howard, Matthew, L. (2009) Middle Ear, Tympanic Membrane, Perforations, California, emedicine from: http://emedicine.medscape.com/article/858684overview Naumann H.H., Helms J., Jahrsdoerfer R. (1998), Head and neck surgery, Volume 2, Thieme Medical Publishers Inc., New York, USA Moller, A.R., 2006, Hearing: Anatomy, Physiology and disorders of the Auditory system, 2nd Ed. Elsevier Inc., Oxford, UK, pp 210-212 www.freedictionary.com http://www.drugs.com/tympanic-membrane-perforation-inpatient care.html Hand book Clinical audiology(by Jack Katz, PH.D) Wikipedia in Cyclopaedia www.medicinenet.com Hearing ( its physiology and pathphysiology) by (Aage R. Moller) Hearing (an introduction to psychological and physiological acoustics) by Stanley A. Gelfand BHA Module lectures, plus BSA procedure Pathology module lectures