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# Tympanic membrane perforation

A hole in the [eardrum](https://durgical.com/en/anatomy/tympanic-membrane/), usually from infection or injury. Most heal on their own within weeks; some need a small operation to close them.

Updated Nov 5, 2026

On this page

- The basics What it is
- Who gets it
- Causes
- Risk factors
- Classification
- In ENT
- In forensic medicine

- Clinical Symptoms and signs
- Red flags
- Diagnosis
- Differential diagnosis
- Complications
- Prognosis

- Treatment Treatment

- Study Test yourself

- Connections Connections

## What it is

A defect in the tympanic membrane that opens a direct connection between the external [ear canal](https://durgical.com/en/anatomy/external-acoustic-meatus/) and the middle ear. It can be acute (infection, trauma) or chronic, when it fails to heal after about three months.

See it in 3D

- [Eardrum](https://durgical.com/en/anatomy/tympanic-membrane/)
- [Ear canal](https://durgical.com/en/anatomy/external-acoustic-meatus/)
- [Malleus](https://durgical.com/en/anatomy/malleus/)
- [Incus](https://durgical.com/en/anatomy/incus/)

## +2

- [Stapes](https://durgical.com/en/anatomy/stapes/)
- [Auditory tube](https://durgical.com/en/anatomy/auditory-tube/)

## Who gets it

Very common in primary care and emergency departments. In children it is mostly caused by acute otitis media; in adults, trauma and chronic otitis media dominate. In Colombia and Latin America chronic suppurative otitis media remains an important cause of persistent perforation and hearing loss.

## Causes

- Acute otitis media with spontaneous rupture of the eardrum
- Chronic suppurative otitis media
- Direct trauma: cotton buds, sticks, foreign bodies, ear irrigation
- Barotrauma: slap on the ear, blast, diving or flying
- Temporal bone fracture after head injury
- Iatrogenic: after removal of ventilation tubes or ear surgery

## Risk factors

- Recurrent acute otitis media in childhood
- Eustachian tube dysfunction
- Inserting objects into the ear canal
- Exposure to explosions, including fireworks
- Diving and flying with a blocked nose

## Classification

- By cause: infectious, traumatic, iatrogenic
- By time: acute or chronic (not healed after about three months)
- By site: central (pars tensa, with a rim of membrane) or marginal/attic (reaching the annulus or pars flaccida, linked to cholesteatoma)
- By size: small, medium, large or subtotal

## Symptoms and signs

- Sudden ear pain that eases when the drum ruptures (in otitis media)
- Ear discharge, which may be bloody after trauma
- Conductive hearing loss
- Tinnitus or a feeling of fullness
- Sometimes brief vertigo

## Red flags

- Vertigo, nystagmus or marked sensorineural hearing loss after trauma (possible perilymph fistula or ossicular injury)
- Facial weakness
- Clear watery discharge after head injury (cerebrospinal fluid leak)
- Penetrating injury of the canal
- Marginal or attic perforation, or persistent foul discharge (suspect cholesteatoma)

## Diagnosis

**Clinical**
Otoscopy shows the hole, its site and size, and any discharge; pneumatic otoscopy shows reduced drum mobility. Tuning forks show a conductive pattern: Rinne negative on the affected side and Weber lateralising to it.

**Tests**
Pure-tone audiometry measures the conductive loss and checks for a sensorineural component; tympanometry shows a high ear-canal volume (flat curve). Culture of the discharge if it persists.

**Imaging**
Not needed for a simple perforation. CT of the [temporal bone](https://durgical.com/en/anatomy/temporal-bone/) after head trauma, or when cholesteatoma or complications are suspected.

## Differential diagnosis

- Retraction pocket or atelectatic eardrum
- Cholesteatoma
- Acute otitis externa with debris hiding the drum
- Monomeric (healed, thin) eardrum segment
- Temporal bone fracture

## Treatment

**Conservative**
Most acute perforations heal on their own within weeks. The ear is kept dry (no swimming, cotton with a water-repellent barrier when showering), and the ear is not irrigated or cleaned with objects.

**Medical**
If there is discharge or infection, non-ototoxic antibiotic ear drops (a fluoroquinolone) and analgesia; aminoglycoside drops are avoided while the drum is open. Systemic antibiotics treat an underlying acute otitis media.

**Procedure**
Paper patch myringoplasty for small, clean traumatic perforations, done by an otolaryngologist.

**Surgical**
Myringoplasty or tympanoplasty for perforations that persist beyond about three months, recurrent discharge, or significant hearing loss; it is usually planned once the ear is dry.

**Acute**
Urgent referral to otolaryngology for vertigo, sensorineural hearing loss, facial palsy, penetrating injury or a temporal bone fracture.

## Complications

- Persistent conductive hearing loss
- Recurrent middle ear infection and chronic suppurative otitis media
- Acquired cholesteatoma from epithelium growing inwards
- Tympanosclerosis
- Sensorineural hearing loss or vertigo with inner ear injury

## Prognosis

Good. Most small traumatic and infectious perforations close spontaneously; large, marginal or infected perforations heal less often. Surgical closure succeeds in most patients.

## Test yourself

Think of the answer, then tap the question to see it.

## What hearing pattern does a tympanic membrane perforation cause?

Conductive hearing loss: Rinne negative and Weber lateralising to the affected ear.

## Which type of perforation raises suspicion of cholesteatoma?

A marginal or attic (pars flaccida) perforation.

## Which ear drops are avoided while the eardrum is perforated?

Aminoglycoside drops, because they are ototoxic; non-ototoxic drops such as fluoroquinolones are preferred.

## When is a perforation considered chronic and referred for repair?

When it has not healed after about three months, or earlier if there is recurrent discharge or significant hearing loss.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/tympanic-membrane-perforation/)

## In ENT

- [Myringoplasty and tympanoplasty](https://durgical.com/en/ent/myringoplasty-and-tympanoplasty/)

## In forensic medicine

- [Explosion injuries](https://durgical.com/en/forensic-medicine/explosion-injuries/)

## Connections

## Related conditions 7

- [Acute otitis media](https://durgical.com/en/conditions/acute-otitis-media/)
- [Otitis media with effusion and chronic suppurative otitis media](https://durgical.com/en/conditions/otitis-media-with-effusion-and-chronic-suppurative-otitis-media/)
- [Cholesteatoma](https://durgical.com/en/conditions/cholesteatoma/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)
- [Hearing loss (conductive and sensorineural, including sudden hearing loss)](https://durgical.com/en/conditions/hearing-loss/)
- [Basilar skull fracture](https://durgical.com/en/conditions/basilar-skull-fracture/)
- [Foreign bodies of the ear and nose](https://durgical.com/en/conditions/foreign-bodies-of-the-ear-and-nose/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Tympanic Membrane Perforation](https://www.ncbi.nlm.nih.gov/books/NBK557887/) (StatPearls (NCBI Bookshelf), 2025).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/tympanic-membrane-perforation/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/tympanic-membrane-perforation/