Perforated eardrum

What is a perforated eardrum?

A perforated eardrum is a tear or hole in the eardrum. It can affect hearing. The extent of hearing loss can vary greatly. For example, small holes may only cause minimal loss of hearing. Larger holes may affect hearing more severely. Also, if the tiny bones (ossicles) behind the eardrum are damaged in addition to the perforation, then the hearing loss would be greater than, for example, one caused by a small perforation away from the ossicles.

With a perforation, there is greater risk of developing an ear infection. This is because the eardrum normally acts as a barrier to prevent bacteria and other germs entering the middle ear.

There may be no symptoms, or there may be symptoms associated with the cause of the perforation. The most common cause of perforation is infection.

Possible symptoms and signs of a perforated eardrum include:

• Changes in how you hear, that may range from slightly muffled hearing to significant loss.

• Noises in your ear - ringing or buzzing (tinnitus).

• Aching or pain in your ear.

• Itching in your ear.

• Fluid leaking from your ear.

• Dizziness.

• The feeling of air coming out of the ear when the nose is blown - blowing the nose usually causes the eardrum to balloon outwards a little but if there is a hole, air will be pushed out of the ear instead.

If your perforated eardrum is caused by a middle ear infection, you may have earache which suddenly gets worse when the drum perforates but then quickly improves or even completely resolves. This is because the perforation usually allows pus to be released from behind the eardrum, relieving pressure.

The symptoms will usually pass once your eardrum has healed and any infection has been treated.

See your GP if you have symptoms of a perforated eardrum. They can usually confirm whether a perforation is present. If you have symptoms of infection, such as fluid leaking from the ear or a high temperature, antibiotic medications may be required. If you have hearing loss that does not improve over time, a hearing test or referral to an ear specialist may be requested.

How is a perforated eardrum diagnosed?

A doctor can usually diagnose a torn (perforated) eardrum simply by looking into the ear with a special torch called an otoscope. However, sometimes it is difficult to see the eardrum if there is a lot of inflammation, wax, or infection present in the ear.

If a hearing test is performed for any reason, for example, if there is also suspected hearing loss, a test of the middle ear known as tympanometry is also usually performed. This can confirm whether a perforation is present.

Causes include:

• Middle ear infections, which can damage the eardrum. In this situation there is often discharge as pus runs out from the middle ear.

• Direct injury to the ear - for example, a punch to the ear.

• A sudden loud noise - for example, from a nearby explosion. The shock waves and sudden sound waves can tear (perforate) the eardrum. This is often the most severe type of perforation and it can lead to significant hearing loss and ringing in the ear (tinnitus).

• Barotrauma. This occurs when there is a sudden change in air pressure, creating a sharp difference between the air pressure outside the ear and in the middle ear, for example, when descending in an aircraft or whilst scuba diving. Pain in the ear due to a tense eardrum is common during height (altitude) changes when flying. However, a perforated eardrum only happens rarely in extreme cases.
  
  See the separate leaflet called Barotrauma to the ear for more details

• Poking foreign objects, such as a cotton bud, into the ear. This can sometimes damage the eardrum.

• Grommets. These are tiny tubes that are placed through the eardrum. They allow air to pass in and out of the middle ear to stop production of the fluid that causes glue ear. When a grommet falls out, there is a tiny hole left in the eardrum. This heals quickly in most cases.

Cross-section of the ear

The eardrum (also called the tympanic membrane) is a thin skin-like structure in the ear. It lies between the outer (external) ear and the middle ear.

The ear is divided into three parts - the outer, middle, and inner ear. Sound waves enter the outer ear and hit the eardrum, causing the eardrum to vibrate.

Behind the eardrum are three tiny bones (ossicles). The vibrations pass from the eardrum to the bones of the middle ear. The bones then transmit the vibrations to the cochlea in the inner ear. The cochlea converts the vibrations to sound signals which are sent down a nerve to the brain, which we 'hear'.

The middle ear behind the eardrum is normally filled with air. The middle ear is connected to the back of the nose by the Eustachian tube. This allows air to move in and out of the middle ear.

Treatment is usually only required if the eardrum does not heal after a few weeks or if complications arise, such as hearing loss or ear infections.

No treatment is needed in most cases

A torn (perforated) eardrum will usually heal by itself within 6-8 weeks. It is a skin-like structure and, like skin that is cut, it will usually heal. In some cases, a doctor may prescribe antibiotic medicines, usually drops, if there is an infection or risk of infection developing in the middle ear whilst the eardrum is healing.

What happens if water passes through a perforated eardrum?

It is best to avoid water getting into the ear whilst it is healing. For example, you may be advised to put a large ball of cotton wool covered with petroleum jelly (eg, Vaseline™) into your outer ear whilst showering or washing your hair. It is best not to swim until the eardrum has healed.

Medical treatment

Occasionally, a perforated eardrum gets infected and needs antibiotics. It is thought that some antibiotic ear drops can occasionally damage the nerve supply to the ear. Your doctor will select a type that does not have this risk.

Surgical treatment

A small operation may be required to treat a perforated drum that does not heal by itself. Various techniques can be used to repair the eardrum, depending on how severe the damage is. This operation may be called a myringoplasty (repair of the perforated eardrum only) or a tympanoplasty (repair of perforated eardrum and inspection of the middle ear bones, the ossicles). These operations are usually successful in fixing the perforation and improving hearing.

However, not all people with an unhealed perforation need medical treatment or surgery. Some people have a small permanent perforation with no symptoms and no significant hearing loss. Treatment is mainly considered if there is hearing loss, as this may improve if the perforation is fixed. Also, swimmers may prefer to have a perforation repaired, as getting water in the middle ear can increase the risk ear infections.

If you have a perforation that has not healed by itself, a doctor who is an ear specialist can discuss options to help decide whether treatment is necessary.