The exact incidence of Tympanic Membrane Perforations and Ruptures is unknown. One study reported greater than 200,000 cases annually. Another study reported 150,000 tympanoplasties are performed per year in the United States.
4% of Native American children had tympanic perforations.
3% of children who had ventilation tubes placed had the condition of chronic perforations.
Traumatic causes of tympanic membrane perforations
- Insertion of objects in the ear canal such as Q tips
- Concussion caused by explosion or a blow to the head area
- Fractures of the temporal bone area
- Barotrauma (air travel or scuba diving)
- Perforation during removal of a foreign body or wax removal
Infection is the principal cause of TMP. Acute Otitis Media is extremely common in children and pressure from the infection may cause rupture of the ear drum. Chronic Otitis Media with perforation may be associated with chronic draining or cholesteatoma formation which is a cyst like structure that can form and can wrap around the bones needed for hearing in the inner ear.
Signs and Symptoms
- Pain of sudden onset
- Bleeding from the canal
- Hearing loss
- Ringing in the ear (tinnitus)
The tympanic membrane is a stiff, translucent diaphragm like structure. Sound waves entering the ear canal cause variations in the pressure and are transmitted through the ossicular chain to the cochlea. In the cochlea, the vibrations are changed into electromechanical energy and are sent via the eighth cranial nerve to the brain.
As stated above, infections are the principal cause of tympanic membrane perforations. Acute infection causes a relative ischemia in the drum area and with the increased pressure of the infection, it can lead to a tear of the eardrum. This tearing event is usually preceded by severe pain.
The current school of thought is that most episodes of otitis media are caused by viruses and therefore no antibiotics are needed. They usually resolve spontaneously. Evidence is now emerging that an increased incidence of acute mastoiditis is resulting from the decreased use of antibiotics. Complications from acute otitis media other than tympanic membrane rupture are brain abscess, meningitis, and sinus thrombosis.
Studies have now indicated that there is a definite association between recurrent episodes of otitis media and increased risk of the development of spontaneous tympanic membrane rupture. In 177 children with acute otitis media and spontaneous perforation, 92% of spontaneous perforation occurred in children with recurrent infections vs. 16.9% of those without recurrent infections.
Ear canal infections rarely cause perforations of the eardrum. Most infectious causes of perforation heal spontaneously without interventions. When the tympanic membrane is intentionally perforated to place pressure equalizing tubes (ventilation tubes) 1% of these patients will have failure to close once the tube is removed.
A major symptom of a TMP that does not heal is hearing loss. These can also be drainage from the area is chronic otitis media is present called otorrhea. This is commonly associated with pain.
Most perforations are diagnosed with using routine otoscopy. Routine formal audiometric evaluation should be accomplished before any repair attempt is done.
Repair of Chronic Tympanic Membrane Perforations
The goal of medical therapy for perforations is control of the drainage (otorrhea) Management of the perforations is greater if the area stays dry and the perforation is small. Small patches can be placed over the area.
Fat grafting can be attempted. Fat is removed from the ear lobe and then tucked into the perforation. The success rate is less than formal tympanoplasty.
Formal tympanoplasty is done usually under general anesthesia . The ear canal is opened depending on the size and location of the perforation. Repair requires grafting usually tissue is removed from he temporalis fascia or synthetic material.
Indications for Surgical Repair
Many people live with perforations that do not heal, however perforations with recurrent infections should be considered for surgical repair. Hearing loss with larger perforations should also be considered for repair.
For those people who are constantly in the water, repair should be considered. (Divers)
In any surgical procedure, risks should always be considered. Every operation done on the tympanic membrane can lead to further hearing loss.
Imaging studies such as MRI are not indicated unless destruction of the ossicular bones or cholesteatoma is suggested
Surgical therapy consists of 3 general categories
- Office treatments. The simplest but least effective is to apply a patch of cigarette paper on the perforation. Initially started in the 1800, it is still done today and has a success rate of 67%
- Fat plugs is another method that can be performed. Fat is obtained usually from the lobe area and after anesthesia the fat is placed into the perforation. The fat plug method has a success rate of 87%.
- Fibrin glue or a patch comprised of hyaluronic acid and a dressing component. The use of fibroblast growth factor in a patch has also been used. Both of these had reported excellent success.
This second category of treatments is to perform tympanoplasty under general anesthesia. An incision is made behind the ear and through the ear canal. Once exposure is obtained the graft is placed over then perforation. The material is usually temporalis fascia.
Tympanoplasty closes the perforation in 90-95% of the cases. Unfortunately, second and third operations may be needed.
Inlay, underlay and overlay
The third category is the surgical technique as to how the graft is placed , the healing potential and the overall operative time for the procedure.
The conventional technique is the underlay. When compared with the butterfly cartilage tympanoplasty, the success rate was comparable but the duration of the surgery was about half in the butterfly procedure with less pain post operatively.
The overlay graft tympanoplasty had a success rate of 96.6%.
Platelet- Rich Plasma
Platelet Rich Plasma is an autologous blood concentrate that contains supra-physiologic amounts of growth factors, cytokines and bio-active substances needed for tissue repair and regeneration. It has been proven in studies the success rate of tympanoplasty repair is augmented by the introduction of PRP to the graft site.
- Role Of Platelet Rich Plasma in Tympanoplasty Indian J Otolaryngol Head Neck Surg 2020 Jun;72(2): 247-250 PMID 32551285
Purpose- To compare the efficacy of platelet rich plasma in tympanoplasty
Study- 82 patients having a large central perforation underwent tympanoplasty. Control group underwent surgery without PRP. The study group had tympanoplasty with PRP by PRP soaked gel foam was placed over the graft. Pre and post- operative audiometry was done.
Results- Success rate of the graft was 85.3% in the control group and 95.1% in the PRP group.
Hearing was 46.3% in the control group and 78% improved in the PRP group.
Conclusion- PRP enhances the success rate in graft uptake early healing with improved hearing
- Comparative Efficacy of Platelet Rich Plasma Applied in Myringoplasty: A Systemic Review and Meta-analysis PLos One 2021 Jan 25:16(1): e 0245968 PMID 33493204
Background- Platelet Rich Plasma is a novel, effective substance that is increasingly utilized for TM perforation repair. This study aims to evaluate the effectiveness of PRP in the application of TM perforation repair.
Results- After meta-analysis of studies 8 studies with 455 participants were eligible
Conclusion- The application of PRP during the TM surgeries can enhance the closure rate, provide hearing improvements and decrease the incidence of postoperative complications. Given the advantages, PRP can be considered and effective treatment for TM regeneration
- Efficacy of Platelet Rich Fibrin in Myringoplasty J Med Sci Jan-Feb 2021;37(1): 212-216 PMID 33437279
Objective- To determine the efficacy of usage of topical autologous platelet rich fibrin in improving outcomes of myringoplasty regarding graft uptake and hearing improvement
Method- 50 participants in whom myringoplasty was done through post auricular approach using the underlay technique. 25 patients topical PRF drops were used. Outcomes were compared after 3 months
Results- graft uptake 78% in PRF vs 52% in controls. Hearing was improved 18dB vs 6dB Infection rate 8% vs 32% in controls
Conclusion- Topical use of Platelet Rich Fibrin during myringoplasty results in improved graft uptake resulting in much improved hearing significant reduction in infection and overall decreased reduction in perforation sizes
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet- Rich Plasma Kits are FDA approved and designed for safety and effectiveness. They are cost effective and easy to use, providing consistency of concentrated product when obtained from the same source.
Additionally, Juventix offers a patent pending LED- Activator to activate the platelets and begin the regenerative process. The activation, a critical step in the release of cytokines and growth factors, is accomplished with light and not with the addition of other chemicals such as Calcium Chloride or Thrombin.
Juventix Regenerative Medical supplies a Bio-Incubator that transforms the Platelet Rich Plasma into an injectable flowable Platelet Rich Fibrin. The PRF, commonly referred to as the “second generation of platelet products” has a broader range of clinical applications and provides outstanding outcomes. In the last study documented here, Platelet Rich Fibrin drops were made and applied to the surgical site for significant improved and documented clinical results.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Dr. Robert McGrath