Description
Case I
Case II
Case III


Description 

Tympanic membrane perforation occurs most often as a result of otitis media (acute or chronic) or ear injury (direct injury, barotrauma). Small perforations, especially in children usually heal spontaneously within few weeks to a few months. Bigger perforation will require surgical intervention. Due to the possible course, the perforations may be divided into the central and marginal. Central perforations can last for years without causing any symptoms besides hearing impairment and periodic leaks from the ear. Marginal perforations involve the edge of the tympanic membrane. In other words there is no eardrum remnants between skin and the perforation. They are more dangerous because squamous epithelium from the skin of the external auditory canal goes to the tympanic cavity and grows to form a cholesteatoma.


Case I

The photo below shows the large central perforation of the tympanic membrane, 4-year-old child, right ear. Perforation covers a large part of the tympanic membrane, in particular the anterior and inferior quadrants from umbo nearly reaching the annulus. The visible mucosa of tympanic cavity is slightly reddened. The remainder of the tympanic membrane is intact (fig. 1 and 1a).

This large perforation occurred as a result of acute otitis media with spontaneous perforation and purulent discharge. It did not heal because it was extensive. After recovering from acute inflammation, the child did not report any symptoms, not even hearing loss.

Tympanic membrane perforation
Fig. 1 Central perforation of the tympanic membrane
Central perforation - scheme
Fig. 1a Central perforation – scheme
  1. malleus handle level
  2. umbo
  3. anterosuperior quadrant
  4. anteroinferior quadrant
  • Persistent perforation of the tympanic membrane should be treated surgically.
  • Range of surgical intervention: myringoplasty with tragal perichondrium.
  • During the operation the surgeon opens the middle ear after external auditory canal skin incision. Then a patch of tragal perichondrium or temporal muscle fascia is harvested and perforation is closed. The graft should extend under the margins of the perforation (the remnants of the tympanic membrane). This technique is called “underlay”.
  • Because the remnants of the tympanic membrane are well supplied with blood, in this case one should expect good effect, perforation closes and the hearing improves.

Case II

The photo shows the marginal perforation of the tympanic membrane, 6-year-old child, right ear. Perforation covers the posterior and inferior quadrants of the tympanic membrane reaching the annulus. From the top of the perforation goes the epidermis covering partially this part of the perforation. At the bottom of the image (posterior quadrant) one can see two bright bands of the epidermis. The epidermis tucks toward the tympanic cavity to form the cholesteatoma. The remainder of the tympanic membrane is intact (fig. 2 and 2a).

The perforation was caused by chronic otitis media. It did not heal spontaneously. The child reported mild hearing loss, without other symptoms and without discharge.

Marginal perforation of the tympanic membrane
Fig. 2 Marginal perforation of the tympanic membrane
Marginal perforation - scheme
Fig 2a Marginal perforation – scheme
  1. umbo
  2. bands of the epidermis
  3. anteroinferior quadrant
  4. posteroinferior quadrant
  • Persistent marginal perforation of the tympanic membrane must be treated surgically.
  • Range of surgical intervention: explorative tympanotomy with removing of the epithelium, myringoplasty with tragal perichondrium.
  • During the operation the surgeon opens the middle ear after external auditory canal skin incision.
  • Then the epithelium is removed from the edge of the perforation and the inner surface of the tympanic membrane, because leaving it will lead to the creation of cholesteatoma.
  • A patch of tragal perichondrium or temporal muscle fascia is harvested and perforation is closed.
  • The graft should extend under the margins of the perforation (the remnants of the tympanic membrane). This technique is called “underlay”.
  • If there are doubts about the radical removal of the epidermis, the surgeon performs mastoidectomy with posterior tympanotomy and removes the epithelium from the facial recess.