EM@3AM: Tympanic Membrane Rupture

Authors: Brit Long, MD (@long_brit) // Reviewed by: Alex Koyfman, MD (@EMHighAK) 

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 31-year-old female presents with right ear pain and decreased hearing. Her symptoms started suddenly after trying to clean her ears with a Q-tip. She denies vertigo, nausea, vomiting, or other facial symptoms. She has no past medical/surgical history and has no allergies.

On examination, her vital signs are normal. You see a small perforation in the tympanic membrane (TM) with no discharge or other trauma.

What is your next step in evaluation and management?

Answer:  Tympanic membrane rupture

Background: 

• The middle ear space is the cavity between the inner and external ear. The TM is the lateral border of the middle ear space.
• The TM has a relatively large surface area compared to the oval window of the inner ear and amplifies sound by a factor of 20.
• Any disruption in function of the middle ear can result in hearing changes.

Causes of TM rupture:

• Blunt trauma to the ear – hand, direct hit, fall
• Penetrating trauma to the ear – Q-tip or other material placed into ear canal, gunshot wound
• Lightning strike
• Barotrauma – air travel, blast injury, scuba diving
• Acoustic trauma
• Infection

History:

• Most patients will present with ear pain in the setting of barotrauma or direct ear trauma.
• Patients may have vertigo/dizziness, nystagmus, nausea/vomiting, ataxia, facial nerve weakness, new onset otorrhea, tinnitus, and/or hearing changes.
• Determine mechanism. In the setting of severe trauma, evaluate for other injuries (head trauma, basilar skull fracture, C spine injury).

Exam:

• TM rupture is a clinical diagnosis. Simple perforation is a rupture with no other serious symptoms and < 25% of total drum surface.
• Complicated/large perforation is associated with hearing loss > 40 dB, vertigo/dizziness, ataxia, facial nerve weakness, large perforation.
• In severe trauma, assess vital signs and ABCs. Evaluate for head trauma/skull or facial fractures.
• Ear exam: auricle, otoscopy of external canal/TM/middle ear.
• Evaluate hearing; significant hearing loss can be present.
• Weber and Rinne tests should be performed for patients with hearing loss.
  • Weber: lateralizes to bad ear in conductive loss, while in sensorineural loss lateralizes to the good ear.
  • Rinne: Conductive loss -> air conduction is greater than bone conduction in good ear, while bone conduction is greater than air conduction in bad ear. Sensorineural loss -> air conduction is greater than bone conduction in both ears.
• Facial weakness (Cranial nerve VII) may be present.

Differential:

• Inner ear pathology: Labyrinthitis, vestibular neuritis, Meniere’s disease, sensorineural hearing loss
• Internal: Otitis media (acute or chronic), bullous myringitis, mastoiditis.
• External: Otitis externa, malignant otitis externa, contact dermatitis, foreign body, otomycosis, cholesteatoma, auricular hematoma or perichondritis, herpes zoster oticus.

Workup:

• Obtain temporal computed tomography without contrast (0.6 mm) in patients with evidence of basilar skull fracture, head trauma with facial nerve dysfunction, hearing loss > 40 dB or vestibular symptoms.
• Head CT may miss injuries of the middle ear due to 1 mm or larger cuts.
• Obtain other imaging based on suspected injury.
• Those with significant hearing loss will need formal audiometry.

Management:

• If critically ill, stabilize patient. Those with suspected C spine injury should be immobilized (C collar).
• Any protruding foreign bodies in the ear canal should be left in place and managed by ENT.
• Assess and update tetanus status as needed.
• Simple, small, isolated perforation: heals in 4-6 weeks, provide antibiotic ear drops for contaminated wounds (external puncture, perforation with water contamination, canal occluded with blood or drainage in those with middle ear trauma) with ciprofloxacin or ofloxacin, keep water out of ear, avoid Valsalva. Follow up with primary care provider. If associated with otitis media in pediatric patients, administer PO antibiotics.
• Complicated or large perforation: management similar to simple perforation but needs urgent evaluation by ENT (within 48 hours).

Disposition:

• Most patients can be managed in the outpatient setting unless other injuries requiring admission are present (subarachnoid hemorrhage, basilar skull fracture, ossicular disruption, facial nerve paralysis, perilymph fistula, refractory nausea/vomiting).
• Ensure those with complicated rupture have ENT follow up.
• Those with hearing changes should have audiology follow up.

Complications: 

• Hearing loss, persistent facial nerve palsy, and cerebrospinal fluid fistula may lead to meningitis.

Key Points:

• TM rupture is divided into simple/isolated versus complicated large.
• Hearing loss, vertigo/nystagmus, ataxia, and/or facial weakness are complicated.
• Assess for other injuries, but diagnosis is clinical.
• Those with complicated injuries or retained FB need ENT consultation.

A 26-year-old man presents to the emergency department with ear pain. He states that he was slapped in the right ear 1 hour prior to arrival. Since then, he reports some decreased hearing on the right side, as well as some bloody drainage from his ear. He denies loss of consciousness, headache, or any pain. On exam, you note the above findings. What is the most appropriate next step in management?

A) Administer oral antibiotics

B) Administer topical antibiotics

C) Emergent consult to otolaryngology

D) No intervention needed at this point

Answer: D

The patient is presenting with a perforated tympanic membrane. Perforations of the tympanic membrane can occur because of direct trauma, barotrauma, acoustic trauma, or infections. Patients typically present with acute pain and hearing loss. Perforations may also be associated with tinnitus and vertigo. On exam, the defect should be clearly visible, and bloody otorrhea may be present as well. Most tympanic membranes heal spontaneously, require no intervention, and are able to be discharged with routine follow-up with otolaryngology and audiology. Patients should be counseled on the importance of avoiding water exposure to the ear canal in the meantime. If the tympanic membrane defect is large or caused by penetrating trauma, more urgent follow-up with otolaryngology is indicated to assess for ossicular chain damage.

Administering oral (A) or topical antibiotics (B) would be appropriate if there was a suspected retained foreign body or if the perforation was caused by an underlying infection but is not necessary in the treatment of isolated tympanic membrane perforations caused by blunt trauma. Emergently consulting otolaryngology (C) would also be inappropriate, as there is no acute intervention necessary to treat isolated tympanic membrane perforations.

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Further Reading:

1. Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol 2005; 119:366.
2. Keogh IJ, Portmann D. Drop weld thermal injuries to the middle ear. Rev Laryngol Otol Rhinol (Bord) 2009; 130:317.
3. Wohlgelernter J, Gross M, Eliashar R. Traumatic perforation of tympanic membrane by cotton tipped applicator. J Trauma 2007; 62:1061.
4. Lasak JM, Van Ess M, Kryzer TC, Cummings RJ. Middle ear injury through the external auditory canal: a review of 44 cases. Ear Nose Throat J 2006; 85:722, 724.
5. Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. J Pediatr 2017; 186:124.
6. Sagiv D, Migirov L, Glikson E, et al. Traumatic Perforation of the Tympanic Membrane: A Review of 80 Cases. J Emerg Med 2018; 54:186.
7. Iloreta AM, Malkin BD. Facial nerve paralysis following transtympanic penetrating middle ear trauma. Ear Nose Throat J 2011; 90:510.
8. Johnson F, Semaan MT, Megerian CA. Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin North Am 2008; 41:597.
9. Aguilar EA 3rd, Yeakley JW, Ghorayeb BY, et al. High resolution CT scan of temporal bone fractures: association of facial nerve paralysis with temporal bone fractures. Head Neck Surg 1987; 9:162.
10. Evans AK, Licameli G, Brietzke S, et al. Pediatric facial nerve paralysis: patients, management and outcomes. Int J Pediatr Otorhinolaryngol 2005; 69:1521.
11. Fitzgerald DC. Head trauma: hearing loss and dizziness. J Trauma 1996; 40:488.
12. Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforations of the tympanic membrane. Clin Otolaryngol 2008; 33:420.
13. Yetiser S, Hidir Y, Birkent H, et al. Traumatic ossicular dislocations: etiology and management. Am J Otolaryngol 2008; 29:31.