PANCE Blueprint EENT (9%)

Tympanic membrane perforation (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

TM Perforation

Patient will present with → pain, otorrhea and hearing loss/reduction

Traumatic perforation of the TM causes sudden severe pain sometimes followed by bleeding from the ear, hearing loss, and tinnitus.

  • Most common causes infection, direct trauma or barotrauma
  • The only class of antibiotics that are non ototoxic are the floxins drops and should be used if you are going to be prescribing drops with a perforated TM. 
  • Most TM perforations are nonurgent and do not require immediate evaluation by an otolaryngologist. Often, these can be managed as an outpatient with drops and pain control to decrease inflammation; ENT follow-up in few days to a week.
  • A significant portion of TM perforations heal spontaneously without intervention because of the TM’s regenerative abilities.
  • Most are uncomplicated with minimal hearing loss (<40 dB) and lack vestibular complaints.
  • Observation of >3 months is a feasible option in select patients with uncomplicated, small perforations.
  • Debate exists over dry-ear precautions. But conservatively, patients should avoid getting water into the external auditory canal and into middle ear space. Typical showering is less of an issue, but swimming in rivers/swimming pools should be avoided until the perforation has healed.
    • For patients who participate in water sports as a part of daily life, such as swimmers and divers, repair is recommended to provide the patient a “safe ear.”
    • Because there is a connection from the outer ear to the middle ear, dry ear precautions are needed to prevent a nidus of infection such as using a cotton ball in the ear during showers and gentle hairdryer use over ear if water enters the ear canal.

Diagnosis is based on otoscopy

Treatment often is unnecessary. Antibiotics may be needed for infection. Surgery may be needed for perforations persisting > 2 mo, disruption of the ossicular chain, or injuries affecting the inner ear.

Treatment of purulence with topical antibiotic drops for 5-7 days will reduce otorrhea

  • The only class of antibiotics that are non ototoxic are the floxins drops and should be used if you are going to be prescribing drops with a perforated TM. 

Perforations with hearing loss >40 dB, any degree of ipsilateral facial weakness, those associated with vestibular symptoms, or those associated with cholesteatoma require referral to ENT; for traumatic perforation, obtain evaluation within 48 hours.

Follow-up should be established with an otolaryngologist to confirm tympanic membrane healing and to obtain an audiogram.

It is vital to reexamine the ear, especially after an episode of infection associated with a perforation, to rule out underlying cholesteatoma or chronic eustachian tube dysfunction, which may be contributing to the perforation.

Perforation examples

Question 1
A 13 year-old presents with pain in his right ear and loss of hearing since yesterday. He has never had an episode like this before. On exam vital signs are T- 38°C P- 70/minute R- 18/minute BP- 90/60 mmHg. Neck is supple, without lymphadenopathy. Right tympanic membrane is not visible; the canal is swollen, with small amount of exudate noted. There is tenderness of the external ear, especially with gentle traction of the tragus. Left tympanic membrane is normal, and the canal is clear. Oropharynx is normal. Which of the following is the most appropriate topical treatment for this patient?
A
Acetic acid solution
Hint:
Acetic acid solution may be used, but the burning sensation associated with it reduces patient compliance. It is usually used in combination with a topical antimicrobial.
B
Erythromycin solution
Hint:
Erythromycin solution is not used to treat otitis externa.
C
Cortisporin otic suspension
D
Gentamicin drops
Hint:
Gentamicin drops are not used in the treatment of otitis externa.
Question 1 Explanation: 
Cortisporin otic suspension is a combination antimicrobial (Neomycin and Polymyxin B) and steroid (hydrocortisone) that is effective to use in the treatment of otitis externa. In addition, the suspension is safe to use in suspected cases of tympanic perforation.
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