Between the outer and middle ear lies the tympanic membrane, or eardrum. It is a thin layer of tissue that is oval in shape and stiff but flexible. The eardrum vibrates in accordance with sound waves. The middle ear bones known as the ossicles transmit these vibrations to the inner ear where the organ of hearing converts it into nerve impulses. Apart from its crucial role in the sense of hearing, the tympanic membrane also separates the outer ear which is contact with the external environment from the more delicate middle and inner ear.
Air enters the middle ear by way of the eustachian tube that runs from the back of the throat. In this way the air pressure in the middle ear remains the same as the pressure in the outer ear. However, the eardrum is capable of withstanding considerable force in terms of sound waves and even changes in ear pressure that causes it to bulge inwards or outwards. In some cases it can rupture or become punctured thereby compromising its role in hearing and separating the outer and middle ear.
What is a perforated eardrum?
A perforated eardrum is a tear in the eardrum (tympanic membrane). It is also known as a tympanic membrane perforation or TMP for short. The common term is a ‘hole in the ear’, however this does not specifically indicate the exact site of the problem as the ear is made up of several sections (outer, middle and inner) and structures like the eardrum, ossicles (middle ear bones), round and oval window and cochlear to name but a few. It is therefore possible for a ‘hole’ to develop in any of these structures.
Although a perforated eardrum seems like a very serious condition, and can be if severe or should it persist, it is not an uncommon ear problem and in most instances does not have any permanent complications. The eardrum is living tissue and can therefore repair itself in most instances, even in recurrent perforations. However, in some instances it is necessary to intervene surgically and repair the perforation either by patching the tear or placing a graft.
Perforated Eardrum Causes
There are several causes of a perforated eardrum which can be broadly classified as infectious or traumatic (injury).
This is the most common causes of eardrum perforation. It is a middle ear infection (otitis media) that is most likely to lead to a perforated eardrum rather than an outer ear infection (otitis externa). These infections may be caused by bacteria, viruses or fungi. Although an infection may cause inflammation of the eardrum itself, it is the pressure buildup within the middle ear that eventually leads to the rupture of eardrum. Fluids or pus that accumulates in the middle ear pushes against the eardrum causing it to stretch. Eventually the eardrum tears as it is unable to withstand the pressure of the congested middle ear.
Trauma to the ear and to the eardrum specifically may be due to a number of different causes. In fact a torn eardrum associated with an infection is in itself an injury as the pressure buildup within the middle ear eventually leads to the perforation rather than the action of the microbes on the eardrum. Barotrauma is the term for injury due to pressure – one of the more common means by which the eardrum is perforated even in the absence of an infection.
- Diving underwater – the pressure of the water in the ear canal.
- Air travel – the pressure within the middle ear may be different from the cabin pressure if the eustachian tube is blocked.
- Slap to the ear either during an assault, accidental slap or falling on the side of the head.
- Loud sound – gunshot close to the ear or an explosion causing the eardrum to bulge excessively in response to the sound waves (acoustic trauma).
- Foreign objects in the ear especially cotton swabs (cue tips), matchsticks and hairpins used to clean the ear. Sometimes this is accidental when a thin solid object enters the ear canal.
- Severe head trauma where the force can be transmitted to the inner structures of the head, including the eardrum thereby damaging it.
Perforated Eardrum Symptoms
It is not uncommon for a very small tear to cause little to no symptoms. However, in many instances where there is a tiny hole the symptoms are so vague to most patients that it remains unnoticed. A perforated eardrum can present with one or more of the following symptoms :
- Ear pain that is of sudden onset and typically sharp in nature. The onset of pain may mark the occurrence of the tear. However, with an infection and the gradual build up of middle ear pressure, the pain tends to gradually worsen and then partly subside once the eardrum is torn as the pressure then releases.
- Ear discharge where fluid or pus, which is sometimes blood stained, leaks out through the ear canal into the environment. This is known as otorrhea. This may be absent in non-infectious cases.
- Tinnitus where there is a ringing or buzzing sound in the ear. These sounds are only perceived but do not actually exist. Sometimes a whooshing sound like wind is due to the flow of air through the tear usually when blowing the nose.
- Hearing loss which may vary depending on the size of the tear and involvement of the middle ear bones (ossicles). This is known as conductive hearing loss.
- Vertigo which is often described as a spinning sensation. More correctly, vertigo is usually described as spinning of the room or environment compared to dizziness where a person feels that they are spinning.
There may be other symptoms that accompany the major symptoms of a perforated eardrum.
- Nausea and vomiting
- Facial pain or weakness
- Smelly ear
Video of a Torn Eardrum
This video shows a ‘hole’ in one eardrum as a result of diving.