FFinalistSouthampton · 2027
ENT
AKT · ENT/Ear & hearing

Perforated tympanic membrane

Rupture of the eardrum (infection, trauma, barotrauma)

Overview

A defect in the tympanic membrane from acute otitis media (most common), direct/penetrating trauma (cotton bud), barotrauma or a blast injury. Most heal spontaneously; the management points are keeping the ear dry and avoiding ototoxic drops.

Recognise

  • Sudden ear pain relief with otorrhoea (when AOM perforates), or sudden pain/bleeding/hearing loss after trauma
  • Conductive hearing loss (size-dependent); tinnitus
  • Otoscopy shows the perforation

Red flags

  • Perforation with vertigo/sensorineural loss after trauma → suspect ossicular/inner-ear injury (perilymph fistula) → urgent ENT; cholesteatoma in a chronic marginal perforation

Differentials & how to tell them apart

Cholesteatomachronic foul discharge + an attic/marginal retraction with squamous debris — needs surgery
Acute otitis media (pre-perforation)intact bulging drum with pain/fever
Otitis externacanal inflammation with an intact drum
Perforated tympanic membrane

Perforated tympanic membrane

Didier Descouens / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Otoscopy; audiometry if hearing loss persists. Persistent perforation/discharge → ENT.

Management

Keep the ear dry + analgesia; most heal spontaneously (avoid aminoglycoside drops)

  1. 1Reassure — most traumatic/AOM perforations heal within 6–8 weeks. Keep the ear dry (water precautions); analgesia; treat associated infection.Gate: If ear drops are needed with a (possible) perforation, use a QUINOLONE (ciprofloxacin), NOT an aminoglycoside — aminoglycosides are ototoxic through a perforation
  2. 2Persistent perforation (>6–8 weeks), recurrent infection, or hearing loss → ENT for review ± myringoplasty; exclude cholesteatoma in chronic marginal perforations.
Keep the ear dry; analgesia — most heal within weeks
Avoid aminoglycoside ear drops — ototoxic through a perforation — use ciprofloxacin if topical treatment of infection is needed
Antibiotics if infected — treat associated AOM/discharge

Key points

Most heal alone. The two safety points: water precautions and no aminoglycoside drops. Vertigo/SNHL after trauma suggests inner-ear injury — refer urgently.

Monitor & prognosis

Healing over weeks; persistent perforation/hearing loss → ENT.

Most heal; large/chronic perforations may need myringoplasty.

Source: NICE CKS; ENT UK