Tympanic membrane perforations generally occur secondary to middle ear infections or result from barotrauma, blunt or penetrating trauma, and rarely lightning strikes or electrical injury. When secondary to trauma, the perforation usually occurs in the anterior or inferior pars tensa, or the thinnest and largest area of the tympanic membrane.

The most common complaints include hearing loss and acute pain. Bloody otorrhea is possible. The first step is to visualize the perforation using otoscopy and clean the ear canal. The perforation can appear slit-shaped or with irregular borders. All patients should be instructed to take water precautions.

Most perforations will heal spontaneously. These patients should be referred to an otolaryngologist for follow-up within a few weeks. Those that do not heal on their own will be considered for surgery.

Patient may present with history of:

• Most commonly, penetrating trauma (usually accidental, self-inflicted, eg, Q-tip damage)
• Thermal trauma in welders (molten slag enters ear)
• Explosive barotrauma (device detonation, fireworks, lightning)
• Nonexplosive barotrauma blasts (slap to the ear, airbag deployment, sports, recreational water activities)

Clinical presentation
Both early and late presentation:

• Hearing loss
• Ear pain
• Nausea and vomiting
• Fascial weakness
• Vertigo
• Imbalance
• Tinnitus

Early presentation:

• Vertigo (more severe injury if persistent)
• Bloody otorrhea

Late presentation:

• Chronic suppurative ear disease (chronic otitis media)
• Purulent otorrhea (indicates chronic disease)
• Larger perforations
• Ossicular discontinuity more common

Other complications of middle ear trauma that could indicate possible membrane perforation:

• Cholesteatoma
• Fascial nerve injuries
• Perilymph fistula

General signs of middle ear injury usually appear 2 days post-injury but as early as 6-12 hours:

• Hemotympanum
• Amber or clear middle ear effusion
• Otorrhea
• Hearing deficit by Weber and Rinne tuning fork tests
• Nystagmus
• Ataxia
• Retroauricular hematoma