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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 111-115

Traumatic perforation of tympanic membrane: A prospective study in a tertiary care institute


Department of ENT, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission16-Jul-2021
Date of Acceptance12-Oct-2021
Date of Web Publication21-Sep-2022

Correspondence Address:
Dr. G M Puttamadaiah
Department of ENT, Bangalore Medical College and Research Institute, Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_112_21

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  Abstract 


Introduction: Traumatic perforation of tympanic membrane (TM) is caused by increase in air pressure due to slapping, road traffic accident, blast injury, syringing, trauma by ear buds, etc., The incidence has been increased in recent times due to increased domestic violence and road traffic accidents. Hence, there is a need for early identification, evaluation, and management to reduce the morbidity. Objectives: The objective of the study was to describe etiologies of traumatic perforation of TM, to assess the findings of pure tone audiometry (PTA) among patients with traumatic perforation of TM, and to determine the outcome. Materials and Methods: This study was done between November 2017 and May 2019 in the department of ENT at Bangalore Medical College and Research Institute on 88 patients with traumatic perforation of TM who were subjected to otoscopic examination, tuning fork tests, and PTA. Patients were followed up on weekly basis. Results: Out of 88 patients, 33 patients (37.5%) were in the age group of 21–30 years. Fifty-four were males (61.36%) and 34 were females (38.63%). Slapping is the most common mode of injury with 50 (56.8%) patients. Left ear 55 (62.5%) was more commonly involved than right ear 33 (37.5%). Small perforation 55 (62.5%) was more common followed by medium-sized perforation 25 (28.4%) and large perforations were the least 8 (9.1%). Multiple quadrants were involved in 33 patients (37.5%). Posteroinferior quadrant was most commonly involved. Deafness (75%) was the most common symptom involving 66 patients. Average time taken for spontaneous healing was 37 days. Mean hearing improvement compared between hearing loss at the time of trauma and after 3 months was 13.18 ± 7.05 dB, which is statistically significant (P = 0.0001). Conclusion: Traumatic perforation of TM spontaneously healed in 80 participants (90.90%), whereas eight participants (9.09%) underwent surgery, i.e., tympanoplasty.

Keywords: Prospective study, traumatic perforation, tympanic membrane


How to cite this article:
Puttamadaiah G M, Bhanuprakash P N, Viswanatha B, Patil KI, Menon P A. Traumatic perforation of tympanic membrane: A prospective study in a tertiary care institute. Indian J Otol 2022;28:111-5

How to cite this URL:
Puttamadaiah G M, Bhanuprakash P N, Viswanatha B, Patil KI, Menon P A. Traumatic perforation of tympanic membrane: A prospective study in a tertiary care institute. Indian J Otol [serial online] 2022 [cited 2022 Sep 28];28:111-5. Available from: https://www.indianjotol.org/text.asp?2022/28/2/111/356442




  Introduction Top


Tympanic membrane (TM) lies at the medial end of external auditory meatus and forms the majority of lateral wall of tympanic cavity. It is oval, forming an angle of 55° with the floor of external auditory meatus, as its posterosuperior (PS) part is more lateral than its anteroinferior (AI) part. It is 9–10 mm vertically, 8–9 mm horizontally, and 0.1 mm thick. It has two parts – pars tensa and pars flaccida. It is made of three layers – outer epithelial, middle fibrous, and inner mucosal.[1]

Traumatic perforation of TM is caused by increase in air pressure due to slapping, road traffic accident, blast injury, syringing trauma by earbuds, etc.[2],[3] Size of perforation is directly proportional to the amount of conductive hearing loss. Up to 88% of traumatic perforation of TM heals spontaneously within 3–10 months. The rate of spontaneous healing is inversely related to the size of perforation.[4]

The incidence of perforation of TM due to trauma has been increased in recent times due to increased domestic violence[5] and road traffic accidents.[6] Hence, there is a need for early identification, evaluation, and management to reduce the morbidity and hence the need for the study.

Objectives

  1. To describe various etiologies of traumatic perforation of TM
  2. To assess the findings of pure tone audiometry (PTA) among patients with traumatic perforation of TM
  3. To determine the outcome of healing in traumatic perforation of TM.



  Materials and Methods Top


In this descriptive prospective study, 88 patients attending otorhinolaryngological department during the period November 2017 to May 2019 were enrolled after the Ethical Committee Clearance.

Inclusion criteria

  • Age between 15 and 50 years
  • Patients willing to give informed written consent
  • History of trauma to the ear.


Exclusion criteria

  • Any form of ear surgery involving TM in the past
  • Previous ear discharge
  • Previously impaired hearing.


All patients willing for taking part in the study were explained in detail about the procedure, and informed consent was obtained for the same. Patients who fulfill the inclusion criteria were enrolled in the study. Detailed history was taken regarding the mode of injury, impaired hearing, tinnitus, earache, bleeding from ear, and vertigo. Otoscopic examination was done with regard to location, size, and shape of TM perforation. Tuning fork tests and PTA were done to assess the type and degree of hearing loss. Initially, medical management was done with oral antibiotics, analgesics, and by asking the patient to keep the ear dry, not to instill ear drops, and not to swim. Patients were followed up on weekly basis to watch for spontaneous healing of perforated TM. Surgical management, i.e., tympanoplasty was performed in patients in whom spontaneous healing of TM did not occur after 3 months of watchful waiting. The patients were followed up for another 3 months postoperatively for graft uptake observed by otoscopic examination, and assessment of improvement in hearing was done using PTA.

Statistical analysis

Data were entered in MS Excel spreadsheet and tested for errors and coded appropriately. Analysis was carried out using the SPSS 17.0 version (IBM, USA). The descriptive statistics are described as proportions and percentages as applicable. The results are expressed as graphs, tables, or charts as necessary and appropriate.


  Results Top


In this study, 88 patients attending the outpatient department with traumatic TM perforation were included. Out of 88 patients, 33 patients (37.5%) were in the age group of 21–30 years [Table 1]. Fifty-four were males (61.36%) and 34 were females (38.63%) [Table 2]. Slapping is the most common mode of injury with 50 (56.8%) patients [Table 3]. Left ear 55 (62.5%) was more commonly involved than right ear 33 (37.5%) [Table 4]. Small perforation [Figure 1] 55 (62.5%) was more common followed by medium-sized perforation [Figure 2] 25 (28.4%) and large perforations [Figure 3] were the least 8 (9.1%) [Table 5]. Posteroinferior (PI) quadrant was most commonly involved [Table 6]. Multiple quadrants were involved in 33 patients (37.5%) [Table 7]. Deafness (75%) was the most common symptom involving 66 patients [Table 8]. Average time taken for spontaneous healing was 37 days [Table 9], [Table 10], [Table 11]. Mean hearing improvement compared between hearing loss at the time of trauma and after 3 months was 13.18 ± 7.05 dB, which is statistically significant [P = 0.0001; [Table 12]].
Figure 1: Small irregular perforation in the anterosuperior quadrant

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Table 1: Age distribution of study participants

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Table 2: Depicting gender distribution of study participants

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Table 3: The mode of injury distribution

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Table 4: The distribution of laterality

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Table 5: Depicting the size of the traumatic tympanic membrane perforation

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Figure 2: Moderate sized traumatic perforation in anteroinferior quadrant

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Figure 3: Depicting large sized traumatic perforation involving anterior inferior and posterior inferior quadrants of tympanic membrane

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Table 6: The quadrant distribution of study participants

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Table 7: The multiple quadrant distribution in study population

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Table 8: Depicting the distribution of presenting complaints

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Table 9: The hearing loss distribution

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Table 10: The management strategy

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Table 11: Depicting the spontaneous healing distribution of study participants

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Table 12: The comparison between initial pure tone audiometry and post 3 months pure tone audiometry values of hearing loss

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  Discussion Top


Age distribution

In this study, 33 patients (37.5%) were in the age group of 21–30 years, followed by 27 (30.68%) participants were in the age group of 31–40 years. Twenty (22.72%) patients were in the age group of 41–50 years and 8 (9.09%) patients were in the age group of 15–20 years which is comparable with the study done by Sarojamma et al.[7] which showed the similar results with the most common age group affected being 21–30 years. Ogah[8] showed the most common age group affected being 11–20 years. A study by Onotai and Oghenekaro[9] describes the common age group affected as 35–45 years which is comparable to second most common age group affected in our study. A study by Mazumder et al.[10] wherein the most common age group affected was 21–40 years similar to our study.

Gender distribution

In this study, the incidence of traumatic perforation is more common among males with 54 males out of 88 study participants (61.36%) and 34 were females (38.63%) which is comparable with the study done by Mazumder et al.[10] where the incidence of traumatic perforation is more common in males (54.16%) compared to females (45.84%).

Mode of injury distribution in study participants

Slapping is the most common mode of injury for traumatic perforation in our study with 50 (56.8%) out of 88 study participants, followed by direct trauma from earbuds 21 (23.86%) and assault 11 (12.5%). Self-fall and RTA were the least cause for traumatic perforation with 4 (4.54%) and 2 (2.27%), respectively. The study done by Sarojamma et al.[7] showed the most common mode of injury was slapping (50%) and direct trauma (28%) which correlates with our study. The study done by Singh et al.[11] describes slap (63.6%) as common cause. The study done by Onotai and Oghenekaro[9] described slap (42.85%) as most common cause. The study done by Mazumder et al.[10] where slapping is described as the most common mode of injury (73%).

Distribution of laterality

In our study, left ear 55 (62.5%) is more commonly involved in traumatic perforation than right ear 33 (37.5%) out of 88 study participants, which is similar to the study done by Sarojamma et al.[7] and Saimanohar et al.[12] wherein left eardrum was most commonly affected (66%).

Perforation size

In this study, small perforation 55 (62.5%) was being more common followed by medium-sized perforation 25 (28.4%) and large perforations were the least 8 (9.1%). The study done by Sarojamma et al.[7] describes 56% of patients having Grade 1 perforation, i.e., of the size of one quadrant.

Quadrant distribution in study participants

Out of 88 patients, multiple quadrants were involved in 33 patients (37.5%). PI quadrant is the most commonly involved in this study as single quadrant in 31 (35.22%) patients, followed by AI quadrant consisting of 17 (19.3%) patients. PS quadrant was involved in four patients (4.5%), and anterosuperior (AS) quadrant was involved in three patients (3.4%). In our study, AI + PI quadrant (45.45%) together was involved in 15 patients which is the most in whom multiple quadrant perforation is seen, followed by AI + PI + PS in eight patients (24.24%), PI + PS in six patients (18.18%), and the least was AI + AS quadrants in four patients (12.12%) out of 33 study participants in whom multiple quadrant perforation was seen.

The study done by Sarojamma et al.[7] showed PI quadrant most commonly affected (58%) which is higher compared to our study. AI quadrant involved in 38% of cases. Thus, lower half of TM is involved in 96% of cases. A study by Singh et al.[11] describes PI quadrant most commonly affected.

Distribution of presenting complaints

Deafness (75%) is the most common symptom in our study involving 66 patients, followed by earache in 42 participants (47.72%), bleeding from the ear was seen in 32 participants (36.36%), tinnitus in 20 (22.72%) study participants, and four patients (4.5%) developed mucopurulent discharge due to secondary infection. They were treated with appropriate antibiotics and observed for spontaneous healing. All four cases healed well at the end of 3 months. The study done by Sarojamma et al.[7] explains that impaired hearing (48%) is the most common presentation, followed by tinnitus (18%), bleeding from ear (14%), and earache (12%).

The study done by Singh et al.[11] explains most common symptom as earache followed by impaired hearing, tinnitus, and bleeding from the ear. The study done by Mazumder et al.[10] showed tinnitus in 161 (76.66%) patients, aural fullness in 131 (62.38%), and hearing loss in 120 (57.14%) patients out of 210 study participants.

Hearing loss distribution

In our study, 54 patients (61.36%) were found to have hearing loss between 26–40 dB.

Twenty-four participants (27.27%) were found to have hearing loss between 15 and 25 dB. Ten patients (11.36%) had hearing loss between 41 and 55 dB which is comparable to the study by Sarojamma et al.,[7] wherein the hearing loss distribution was more common between 26 and 35 dB.

Spontaneous healing versus surgery

In this study, spontaneous healing of traumatic perforation of TM occurred in 80 participants (90.90%), whereas eight participants (9.09%) underwent surgery, i.e., myringoplasty in whom the traumatic perforation was not healed spontaneously even after 3 months. This is due to large perforation involving multiple quadrants. Surgical management, i.e., myringoplasty was performed using temporalis fascia graft by postauricular approach. The patients were followed up for another 3 months postoperatively for graft uptake observed by otoscopic examination and assessment of improvement in hearing was done using PTA. Our study correlates with the results of study done by Singh et al.,[11] Ogah,[8] and Mazumder et al.[10]

Spontaneous healing time distribution in study participants

Average time taken for spontaneous healing in our study is 37 days. Shortest was 21 days and the longest was 58 days. Spontaneous healing occurred most commonly between 31 and 40 days in 38 study participants (43.18%), followed by 41 and 50 days in 27 participants (30.68%), 21 and 30 days in 13 participants (14.77%), 51 and 60 days in two participants (2.27%) which is comparable to the study done by Sarojamma et al.[7] wherein average time taken for healing is 34.78 days. The shortest was 21 days and the longest was 75 days.

Hearing assessment after 3 months by pure tone audiometry

In our study, 58 participants (65.9%) showed hearing improvement in the range of 16–20 dB, followed by 19 participants (21.59%) showed hearing improvement in the range of 10–15 dB, seven participants (7.95%) showed improvement in between 21 and 25 dB and four patients (4.54%) showed hearing improvement between 26 and 30 dB out of 88 study participants.

The mean hearing loss in our study was 32.03 ± 7.85 dB in 88 study participants. Mean hearing improvement assessed after 3 months of spontaneous healing and surgery was 18.85 ± 4.75 dB. Mean hearing improvement compared between hearing loss at the time of trauma and after 3 months was 13.18 ± 7.05 dB, which is statistically significant (P = 0.0001).


  Conclusion Top


Traumatic perforation of TM spontaneously healed in 80 participants (90.90%), whereas eight participants (9.09%) underwent surgery, i.e., tympanoplasty. This shows that traumatic perforations heal spontaneously in majority of the patients, requiring surgical intervention only in a few cases with large perforations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wright T, Valentine P. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. Great Britain: Hodder Arnold; 2008.  Back to cited text no. 1
    
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Mills R, Nunez D, Toynton S. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. Great Britain: Hodder Arnold; 2008.  Back to cited text no. 2
    
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Francis H. Cumming's Otolaryngology Head and Neck Surgery. 6th ed. Canada: Paul W Flint; 2015.  Back to cited text no. 3
    
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Welling B, Packer M. Ballenger's Otorhinolaryngology Head and Neck Surgery. 17th ed. Shelton, Connecticut: Patricia Bindner; 2009.  Back to cited text no. 4
    
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Kaur R, Garg S. Addressing domestic violence against women: An unfinished agenda. Indian J Community Med 2008;33:73-6.  Back to cited text no. 5
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Sharma SM. Road traffic accidents in India. Int J Adv Integr Med Sci 2016;1:57-64.  Back to cited text no. 6
    
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Sarojamma, Raj S, Satish H. A clinical study of traumatic perforation of tympanic membrane. IOSR J Dent Med Sci 2014;13:24-8.  Back to cited text no. 7
    
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Ogah S. Traumatic tympanic membrane perforation in Lokoja, Nigeria: A review of 43 cases. Nitte Univ J Health Sci 2016;6:68-70.  Back to cited text no. 8
    
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Onotai LO, Oghenekaro EN. Traumatic tympanic membrane perforations: Management outcomes in a resource poor country. J Med Med Sci 2016;7:42-6.  Back to cited text no. 9
    
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Mazumder JA , Nasir SM, Rashid S, Khan AM. Traumatic perforation of tympanic membrane: A rural profile of Bangladesh. Med Today 2016;28:79-82.  Back to cited text no. 10
    
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Singh BR, Sahu VB, Thakral A, Sankar L, Pandey A, Parveen S, et al. Observational study of traumatic tympanic membrane perforations in relation to aetiology and management. J Evid Based Med Healthc 2016;3:2283-6.  Back to cited text no. 11
    
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Saimanohar S, Gadag RP, Subramaniam V. Management of traumatic perforations of the tympanic membrane: A clinical study. Int J Otorhinolaryngol Clin 2015;7:114-6.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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