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This injury is not an uncommon scenario. Sometimes it occurs as a result of accidental injury as a result of insertion into the ear of a cotton bud or harpin. People do this to remove wax or with otitis externa (swimmers ear also referred to as an ear canal infection). It can also occur with rapid pressure changes (barotrauma) or loud sounds.

The perforation leads to an annoying conductve hearing loss perceived as a dulling of the hearing on that side. It is also is painful over the first few days in the affected ear with mucoid discharge.

It is important to have the ear examined properly. A hearing test should be undertaken as although a perforation can cause a decrease in the level of hearing more significant losses can occur as well if the ossicular chain (small bones that conduct sound in the middle ear) is damaged or if the inner ear is damaged.

I usually take a careful history, examine the ears and if it is a clean perforation advise the patient about appropriate ear care hygeine. I usually do not give oral antibiotics or ear drops if the perforation looks clean. Most traumatic peforations heal if given 6-8 weeks  and if they do not then an operation to close them may be considered - myringoplasty.

Anatomy Physiology

The ear drum is composed of two parts, a pars tensa which accounts for the majority of the visible drum and the pars flaccida which accounts for the upper one fifth of the ear drum. Sound is transmitted through the eardrum to the ossicles (tiny bones of the middle ear), these in turn transmit the sound to the cochlea (organ of hearing). Occasionally due to ear disease, trauma or significant infections a perforation / hole in the ear drum occurs. When this happens the patient may be completely asymptomatic but often they have a degree of discharge from the ear and possibly some hearing loss. The degree of hearing loss depends on the integrity of the small bones in the ear and the size / position of the perforation.

Myringoplasty

The hole / perforation in the eardrum can be repaired using an operation called a ‘myringoplasty’. This operation can sometimes be done through the ear canal but occasionally an incision is used behind the ear or above it. The perforation edges are freshened to encourage new growth and a graft is placed under the eardrum as a template for the new drum to grow over. The ear canal then has a dressing placed inside it and this usually comes out some 7-10 days later in the Out-patient clinic.

There is a failure rate associated with the operation and this is dependant on the site of the perforation and the size. Occasionally people feel slightly unsteady following the operation. It is important not to undertake any heavy lifting or blowing of the nose in the postoperative period as this changes the middle ear pressures and it may cause graft failure. The ear and dressing must be kept meticulously dry in the post-operative period until the surgeon agrees for the patient to go swimming again.