1. Tympanic membrane perforation
A perforated eardrum or punctured eardrum is a rupture or perforation (hole) of the eardrum which can occur as a result of otitis media (ear infection), trauma (e.g. by trying to clean the ear with sharp instruments), explosion, noise or surgery (accidental creation of a rupture)

2. Etiological factors Infections of the middle ear – damage the eardrum
Direct injury to the ear – punch to the ear
A sudden loud noise – explosion
Barotrauma – altitude change, pressure varies.
During cleaning the ear
Rupture during surgery

3. Clinical features Pain Discomfort Hearing change or loss
Fullness of ear
Ringing sensation – tinnitus
Blood tinged discharge from ear
Pus discharge when the cause is otitis media
vertigo

4. Types of eardrum perforations​
Perforation at margin of the eardrum
This is a perforation that occurs at the margin of the eardrum - where the eardrum and ear canal come together.
Central eardrum perforation
A perforation can occur in any location on the eardrum. The size of the perforation varies from a small opening to a total (entire) eardrum perforation.
Attic perforation of the eardrum
This is a perforation in the superior part of the eardrum. This is referred as an attic perforation.

5. Diagnostic procedures
History collection
Physical examination
Otoscopic examination
Tympanometry – to note the pressure
Audiometry – hearing test

6. Management – medical No treatment is needed in mild cases.
Tympanic membrane with small torn and holes will heal by itself in most cases.
A torn (perforated) eardrum will usually heal by itself within 6-8weeks.
Advise the patient to keep the ear dry and clean.
Avoid water getting into the ear – apply cotton while showering or washing hair.
Avoid swimming until it healed.

7. Antibiotics can be prescribe if any risk for infection
Analgesics for otalgia
If perforated eardrum is due to foreign body in the ear, do not try to remove it self.

8. Surgical management Indication – unhelaed torns and large torns
Tympanoplasty – it is the surgical correction of the perforated eardrum
Myringoplasty – closure of perforation is called as myringoplasty
Ossiculoplasty – ossicular reconstruction is called ossiculoplasty

9. Tympanoplasty
Microsurgical procedure uses patients own tissues (autologous grafts) to reconstruct the tympanic membrane
Grafts may be taken from different areas includes temporalis facia.
Alloderm grafts (from synthetic materials) may be used if patients have multiple previous surgeries
Homografts and xenografts have less successful rate

10. Approches
Post aural
End aural
Trans canal

11. Post aural and end aural approach

12. Trans canal approach

14. Classification of tympanoplasty
Type I – involves repair of the tympanic membrane alone (myringoplasty)
Type II – involves repair of the TM and middle ear in spite of slight defects in the ossicles
Type III – involves removal of ossicles when a large defect of malleus and incus. In this tympanic membrane is repaired and directly connected into the stapes
Type IV – repair when the stapes foot plate is movable but ligament is missing
Type V – repair of fixed stapes footplate.

15. Complication of surgery
Bleeding or infection
pain
Facial nerve palsy – rarely permanent
Tinnitus
Loss of taste last few weeks
Dizziness for a short time
Partial or total loss of hearing may rarely occur

16. Activity - Avoid strenuous activity.
Walking is a normal activity that can be started straight away.
Keep the ear dry. Cover ear while taking a bath or shower.
Use cotton ball coated with Vaseline to protect the ear.
Do not lift anything heavier than 20 lb during the first postoperative week.
Sneeze with your mouth open.
Blow your nose gently or avoid blowing nose.
Avoid air travel during the first two weeks.

17. Prevention
Some causes of ruptured eardrums cannot be prevented or avoided. A little caution can lower the risk.
Treat ear infections early.
Avoid flying or scuba diving if have sinus infection or upper respiratory tract infection.
During fly or scuba dive, pinch nose and swallow air frequently to help equalize the pressure.
Never put anything in your ear, even to clean it.
Wear proper ear protection such as ear plugs or protection designed for sports activities.