Download Condition: Traumatic tympanic perforation Definition: Perforation of

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:
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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).
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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.
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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)
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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:
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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
perforation)
LEFT
-10
-10
0
0
10
10
20
20
30
30
Hearing level (dB)
Hearing level (dB)
RIGHT
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
Notes: PTA results indicate a unilateral mild-moderate sloping conductive 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
labyrinthine window rupture caused by the perforation (Naumann et al 1998, pp136).
Tympanometry
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 T.M 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. 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. These results indicate that the tympanic
membrane is functioning ‘normally’ in the right ear and from this we can infer
that there are no current middle ear abnormalities.
Acoustic reflexes
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 :
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
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www.freedictionary.com
http://www.drugs.com/tympanic-membrane-perforation-inpatient
care.html
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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