Tympanic membrane (TM) perforation Short orientation
A tympanic membrane perforation is a full‑thickness defect of the tympanic membrane. In the emergency department it most commonly follows acute otitis media or trauma (penetrating injury, barotrauma/blast, blunt head injury).
Most perforations heal spontaneously; the ED focus is confirmation, complication screening (hearing loss, vestibular or facial nerve involvement, contaminated penetrating injuries, skull‑base fracture) and appropriate safety‑netting and referral (NICE NG91, NG98; GOV.UK).
Epidemiology and natural history
- Most TM perforations re‑epithelialise spontaneously over weeks to months.
- Traumatic and blast‑related perforations also have high spontaneous healing rates.
- Persistent symptomatic or large defects are uncommon; surgical repair (myringoplasty/tympanoplasty) is usually considered only after a period of observation - commonly if persistent at ~3 months.
- Local practice often arranges earlier audiology/ENT review at 2-6 weeks (GOV.UK; NICE NG98).
Causes and mechanisms
- Infective: acute otitis media with spontaneous rupture and otorrhoea.
- Penetrating trauma: foreign bodies (cotton buds, hairpins), iatrogenic instrumentation - higher risk of ossicular damage, contamination and chronic disease.
- Barotrauma: diving, rapid altitude change, direct blow to the ear.
- Acoustic/blast injury: explosions, gunfire - may be associated with inner ear injury.
- Head injury: basilar skull or temporal bone fracture may cause haemotympanum and perforation.