Middle Ear, Tympanic Membrane, Perforations 

Updated: Apr 23, 2018
Author: Matthew L Howard, MD, JD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Practice Essentials

Tympanic membrane perforations (TMPs) can result from disease (particularly infection), trauma, or medical care. Perforations can be temporary or persistent. Effect varies with size, location on the drum surface, and associated pathologic condition.

Infection is the principal cause of tympanic membrane perforation (TMP). Traumatic perforations occur from blows to the ear, severe atmospheric overpressure, exposure to excessive water pressure (eg, in scuba divers), and improper attempts at wax removal or ear cleaning.

Perforations without infection or cholesteatoma are not painful. The patient may report audible whistling sounds during sneezing and nose blowing, decreased hearing, and a tendency to infection during colds and when water enters the ear canal. Perforation with infection typically results in copious purulent drainage, which may be sanguineous in both acute and chronic perforation.

Diagnosis and management

Most tympanic membrane perforations (TMPs) are diagnosed using routine otoscopy. Small perforations may require otomicroscopy for identification. Some hearing screening programs include middle ear impedance testing.

Screening tympanometry may reveal abnormalities consistent with perforation. Confirmation still requires examination.

Always perform audiometry upon initial tympanic membrane perforation (TMP) diagnosis and again before any repair attempt, whether in the office or in the operating room.

The goal of medical therapy for perforations is controlling otorrhea. Topically applied eardrops carry the risk of ototoxicity, so avoid eardrops containing gentamicin, neomycin sulfate, or tobramycin in the presence of TMP. Systemic antibiotics are occasionally used when controlling otorrhea from a TMP.

With regard to surgery, the first option is to perform one of the available office treatments. Such treatments have the best chance of working when the perforation is small and involves neither the umbo nor the annulus. Several methods apply.

The simplest, but least effective, in-office operation is cauterization of the edges of the tympanic membrane perforation (TMP) with a caustic, such as trichloroacetic acid (10% solution), followed by application of a small patch of cigarette paper.

Another in-office treatment, a fat-plug tympanoplasty, is performed by obtaining a small plug of fat from the postauricular sulcus with the patient under local anesthesia. The tympanic membrane perforation (TMP) is prepared by anesthetizing its margins with carefully applied phenol solution. Next, the edges are mechanically débrided with microcup forceps. The fat is then tucked into the perforation, extending both into the canal and into the middle ear space.

The second option is to perform tympanoplasty with the patient under local or general anesthesia. An incision may be made behind the ear or entirely through the ear canal, depending on the location and size of the tympanic membrane perforation (TMP). Repair requires preparation of a suitable bed for placement of a graft. By far, the most commonly used grafting material is postauricular fascia. Grafts may be placed medially or laterally to the perforation, or in a combined position.[1]

Epidemiology

Frequency

Incidence of tympanic membrane perforation (TMP) in the general population is unknown. One survey found that that 4% of a population of Native American children had tympanic membrane perforation (TMP).[2] Another study found that 3% of children treated with ventilation tubes had the condition.[3] However, the incidence in the general population has not been studied. Even the exact number of surgical tympanic membrane perforation (TMP) repairs performed each year is unknown. Analysis of government statistics indicates that perhaps 150,000 tympanoplasties are performed per year in a population of 280 million.

Etiology

Infection is the principal cause of tympanic membrane perforation (TMP). Acute infection of the middle ear may cause a relative ischemia in the drum concurrent with increased pressure in the middle ear space. This leads to a tear or rupture of the eardrum that is usually preceded by severe pain. If the perforation does not heal, it leaves a residual tympanic membrane perforation (TMP).

A prominent school of thought now advocates less aggressive use of antibiotics. Those who hold this position recognize that many episodes of otitis media are caused by viruses, so they resolve spontaneously; advocates of this position desire to slow emergence of antibiotic-resistant bacterial strains. Evidence is emerging that an increased incidence of acute mastoiditis is resulting from reduced use of antibiotics.[4] Time will tell whether increased incidence of perforation and other complications of otitis media, such as brain abscess, meningitis, and septic sigmoid sinus thrombosis, also occur.

A prospective study by Marchisio et al indicated that an association exists between recurrent episodes of acute otitis media (AOM) and an increased risk for the development of spontaneous tympanic membrane perforation. The study involved 177 children with AOM complicated within 12 hours by spontaneous tympanic membrane perforation. Within that group, recurrent spontaneous tympanic membrane perforation occurred in 92% of those with recurrent AOM and in only 16.9% of those without recurrent AOM. The most common pathogen detected in the middle ear fluid of the study’s children was nontypeable Haemophilus influenzae.[5]

Ear canal infections rarely cause tympanic membrane perforations (TMP). When this occurs, it is often associated with infection by Aspergillus niger.

Traumatic perforations may result from blows to the ear (eg, being struck with the flat of the hand; falling from water skis with the head hitting the water surface, ear down).[22] Exposure to severe atmospheric overpressure from an explosion can tear the drum.[6] Tympanic membrane perforation (TMP) from water pressure occurs in scuba divers, usually in a drum with atrophy from previous disease. Objects used to clean the ear canal can perforate the drum.

Inexpertly performed irrigation of the ear canal for wax can lead to perforation. In some settings, when irrigation for cerumen is relegated to medical assistants, otolaryngologists may see 10-20 patients per year with this injury. Evidence exists that such perforations are less likely to heal spontaneously.[7] Tympanic membrane perforation (TMP) is intentionally created whenever a surgeon makes an incision in the eardrum (myringotomy). When pressure-equalizing tubes (ventilating tubes) are placed, the TMP purposely is held open. Failure of surgically created openings to heal when the tube extrudes results in chronic tympanic membrane perforation (TMP).

Pathophysiology

The eardrum tends to heal itself. Even eardrums that have been perforated multiple times often remain intact. At times, a perforation heals with a thin membrane consisting only of mucosal and squamous epithelial layers without a fibrous middle layer. Such a neomembrane may be so thin that it can be mistaken for a perforation instead of a healed perforation. Neomembranes may retract deeply into the middle ear, sometimes making them more difficult to distinguish from actual perforations. Examination under the operating microscope resolves ambiguity. Deep retraction, especially in the posterior superior quadrant of the drum, may presage formation of cholesteatoma.

The presence of perforation renders the ear more susceptible to infection if water enters the ear canal. If bacteria-contaminated water passes through the perforation, infection can result. Water surface tension may protect the ear from penetration through a very small perforation. This explains higher infection rates from hair washing than from swimming activities (ie, soap lowers surface tension so water can enter the middle ear). Presence of perforation is an absolute contraindication to irrigation for cerumen removal. History of perforation is also an absolute contraindication unless personal knowledge derived from prior examination indicates an intact drum.

A study by Park et al indicated that perforation size and pneumatization of the middle ear and mastoid affect the degree of conductive hearing loss in cases of tympanic membrane perforation. The study involved 42 patients who underwent tympanoplasty type I, or myringoplasty, with a greater preoperative mean air-bone gap (ABG) found in association with larger perforation size and with a smaller middle ear and mastoid pneumatization volume.[8]

A prospective study by Pusz and Robitschek reported that subacutely, patients in the study who suffered a tympanic membrane perforation from a combat-related blast injury had both conductive and sensorineural hearing loss, with the latter making up 49% of the loss.[9]

Presentation

Perforation symptoms may include audible whistling sounds during sneezing and nose blowing, decreased hearing, and a tendency to infection during colds and when water enters the ear canal. Copious purulent drainage, which may be sanguineous in both acute and chronic perforation, confirms both perforation and infection. Ear canal infections also can cause purulent drainage, but usually in lesser amounts. Perforations uncomplicated by infection or cholesteatoma are never painful. Presence of pain should alert the physician to a concurrent disease process. Perforations accompanied by otorrhea or cholesteatoma are usually not painful.

Indications

Many persons live their lives with tympanic membrane perforations that are entirely without symptoms. Repair of such lesions is usually not indicated. Perforations may be associated with recurrent infection when exposed to water. In swimmers, divers, and other water sports enthusiasts, repair may be indicated as a quality-of-life issue. Hearing loss may be present, especially with larger perforations, and may be a reason for repair.[10] Because a risk to residual hearing exists with every operation on the ear drum, a risk-benefit analysis in which the patient participates is mandatory.[11] For example, question whether the person may be helped just as much with use of a hearing aid.

Relevant Anatomy

The tympanic membrane, also called the eardrum (or just the drum), is a stiff (but flexible), translucent, diaphragmlike structure. The eardrum moves synchronously in response to variations in air pressures, which constitute sound waves. The drum's vibrations are transmitted through the ossicular chain to the cochlea. In the cochlea, vibratory mechanical energy changes to electrochemical energy and streams via the eighth cranial nerve to the brain. The tympanic membrane and its attached ossicles thus act as a transducer, changing one form of energy into another form. See the image below.

Tympanic membrane (TM) as continuation of the uppe Tympanic membrane (TM) as continuation of the upper wall of external auditory canal (EAC) with angle of incline up to 45 degrees on the border between middle ear and the EAC.

The tympanic membrane has 2 distinct zones. The larger of the 2 zones is the pars tensa. This zone consists of a tough and resilient fibrous layer with a diaphanous mucosal layer inside and squamous epithelium outside. The smaller zone is the pars flaccida, which lies superior to the suspensory ligaments of the malleus and lacks a fibrous layer. Perforations of this area often are described as more frequently associated with complications. This is true if the definition of TMP includes depressions of the drum into the middle ear, forming saclike structures (retraction pockets). Clearly, such pockets are more often associated with cholesteatoma formation.

Behind (or medial to) the drum is the middle ear. In front of the drum (or lateral or exterior) is the ear canal. The drum lies at an angle to the bore of the ear canal, creating a vestibule, which can retain cerumen or debris. The malleus is invested by the fibrous layer of the tympanic membrane, securely incorporating it within the drum.

Contraindications

Tympanic membrane perforation (TMP) may be unilateral or bilateral. Select the worse-hearing ear first when performing bilateral tympanic membrane perforation (TMP) repair. If increased hearing loss complications ensue, the better-hearing ear remains uninjured. For the same reason, if tympanic membrane perforation (TMP) is present in a patient's single hearing-capable ear, only incipient life-threatening complications justify repair attempts.

 

Workup

Imaging Studies

Radiography and MRI are of no value unless the clinical picture suggests ossicular destruction and/or cholesteatoma. Asymptomatic perforations, especially if hearing is near normal, require no imaging studies.

Other Tests

See the list below:

  • Most tympanic membrane perforations (TMPs) are diagnosed using routine otoscopy.

  • Small perforations may require otomicroscopy for identification.

  • Some hearing screening programs include middle ear impedance testing.

  • Screening tympanometry may reveal abnormalities consistent with perforation. Confirmation still requires examination.

  • Always perform audiometry upon initial TMP diagnosis and again before any repair attempt, whether in the office or in the operating room.

    • Preoperative and postoperative audiography should always be performed. A major conductive loss not only alerts the surgeon to the possible existence of ossicular lesions, but documentation of a preexisting sensorineural hearing loss may protect the surgeon from later allegations that the surgery caused the hearing loss.

    • Audiometry often reveals normal hearing. The presence of mild conductive hearing loss is consistent with perforation, and a conductive component of at least 30 dB indicates possible ossicular discontinuity or a pathologic condition.

Diagnostic Procedures

In rare cases, otomicroscopy and impedance studies still leave the tympanic membrane perforation (TMP) diagnosis questionable. To provide evidence of perforation (in the form of a stream of bubbles), fill the ear canal with sufficient distilled water or sterile saline to cover the tympanic membrane and have the patient perform the Valsalva maneuver. A negative test result is suggestive but not definitive. A positive test result is caused only by tympanic membrane perforation (TMP).

Histologic Findings

In chronic tympanic membrane perforation (TMP), squamous epithelium is found adjacent to middle ear mucosa and creates a perforation edge with no raw surface. Such healing of the perforation edge is undoubtedly a contributing factor to perforation persistence.

 

Treatment

Medical Therapy

Medical therapy for perforations is directed at controlling otorrhea. Take into account ototoxicity risk from topically applied eardrops when treating ear infections concurrent with tympanic membrane perforation (TMP). Infection alone occasionally can cause sensorineural hearing loss. Clinical toxicity from eardrops in the presence of ear infection has not been demonstrated unequivocally, although experiments in animals clearly demonstrate a correlation. Legal implications of administration of ototoxic eardrops preceding sensorineural hearing loss are clear. For this reason, avoid eardrops containing gentamicin, neomycin sulfate, or tobramycin in the presence of tympanic membrane perforation (TMP). When they are used, substitute a less toxic alternative as soon as drainage and mucosal edema begin to subside. Avoiding contamination of the middle ear space with water via the tympanic membrane perforation (TMP) is critical in minimizing otorrhea from a perforation.

A retrospective study of patients with traumatic tympanic membrane perforation greater than one quarter the size of the membrane found that topical application of either epidermal growth factor (EGF) or ofloxacin otic drops reduced healing time over that associated with observation.  Healing with EGF and ofloxacin otic drops took a mean 12.6 and 12.9 days, respectively, compared with 35.7 days for observation. The actual closure rates for the three treatment methods, however, did not differ significantly.[12]

A prospective study by Lou et al also found ofloxacin otic drops to be effective, reporting reduced closure time in medium- and large-sized traumatic tympanic membrane perforations. In this study, which included 145 patients, closure rates for large perforations were higher for the ofloxacin group than for patients treated with observation.[13]

Systemic antibiotics are occasionally used when controlling otorrhea from a TMP. Antibiotics (eg, trimethoprim-sulfamethoxazole, amoxicillin) directed at typical respiratory flora suffice in most cases. Overgrowth with Pseudomonas aeruginosa or resistant Staphylococcus aureus may occur. Failure of drainage to clear after several days' therapy may require alteration of therapy following culture and sensitivity tests. A tendency of the ear canal to pseudomonad overgrowth indicates that the most accurate testing can be obtained by suctioning a culture specimen (under microscopic control) directly from the middle ear through the perforation.

Under routine circumstances, the surface tension of water may prevent it from entering the middle ear through a small perforation. The addition of soap reduces the water tension. The ear is therefore at greater risk of infection during hair-washing or bathing than from plain water.

Surgical Therapy

Treatment of tympanic membrane perforation (TMP) falls into 3 categories. No treatment is necessary for nonswimming patients with minimal hearing loss and no history of recurrent ear infection. A hearing aid may prove the only necessary treatment for patients with symptomatic hearing loss but no infection or swimming history. Two options exist for patients who are not in either category.

Office treatments

The first option is to perform one of the available office treatments. Such treatments have the best chance of working when the perforation is small and involves neither the umbo nor the annulus. Several methods apply.

The simplest, but least effective, method is to cauterize the edges of the tympanic membrane perforation (TMP) with a caustic, such as trichloroacetic acid (10% solution), and then apply a small patch of cigarette paper. This technique was developed in the 1800s; it presumably remains in the repertoire because it sometimes works. Mechanical stripping of the perforation margin (with topical anesthetic or without) before applying the patch slightly increases the success rate.

A fat-plug tympanoplasty can be performed. Obtain a small plug of fat from the postauricular sulcus with the patient under local anesthesia. Prepare the tympanic membrane perforation (TMP) by anesthetizing its margins with carefully applied phenol solution. Next, mechanically débride the edges with microcup forceps. The fat is then tucked into the perforation, extending both into the canal and into the middle ear space.

The paper-patch method has a reported success rate of 67%; the fat-plug tympanoplasty of 87%.[14]

Niklasson and Tano studied the use of a Gelfoam plug in combination with surgical removal of the perforation edges. They concluded that although additional comparative studies are recommended, the plug seems to result in about the same closure rate as the fat plug technique in persistent small ear drum perforations.[15]

Another successful office treatment, which has the major disadvantage of requiring 6-10 weekly postsurgical office visits, is the irritant oil method.

In this method, freshen the perforation by stripping the margin using microcup forceps. Performed carefully, this can often be accomplished without anesthetic. If necessary, use a small amount of phenol solution for anesthesia. Apply a cotton ball that is 1-2 mm larger than the diameter of the perforation to the tympanic membrane perforation (TMP). The patient then instills a solution of irritative and aromatic oils daily into the ear. The solution is dispensed in 30-mL dropper bottles and is formulated by the pharmacy (all substances United States Pharmacopoeia [USP] grade) as 2 mL eucalyptol, 1.10 mL methyl salicylate, 0.39 g thymol, 0.455 g menthol, 1.20 mL oil of orange, 20.25 g sifted powdered sodium borate, 20.25 g powdered boric acid, 60 mL of 90% ethyl alcohol, saffron to suit for color, and water in a sufficient quantity to make 5000 mL. Change the cotton weekly. Repeat edge freshening if no progress is seen.

This nonsurgical method was initially reported to have a 70% success rate, and this author has obtained similar results using it as the sole therapy for perforations occupying less than 25% of the drum area.[16, 17]

Other recently reported forms of office treatment use fibrin glue or a patch composed of a hyaluronic acid ester and a dressing component. The use of basic fibroblast growth factor with a proprietary patch that consists of a silicone layer and atelocollagen has been described. Excellent success has been reported, but with very small numbers of patients. Time will tell if these new techniques will prove useful additions to treatment options.

Tympanoplasty

The second option is to perform tympanoplasty with the patient under local or general anesthesia. An incision may be made behind the ear or entirely through the ear canal, depending on the location and size of the tympanic membrane perforation (TMP). Repair requires preparation of a suitable bed for placement of a graft. By far, the most commonly used grafting material is postauricular fascia. Allograft tympanic membranes obtained from cadavers, once abandoned because of fear of transmitting viral pathogens, are again being used. Other substances, such as the urinary bladder matrix, are being evaluated.[18] Grafts may be placed medially or laterally to the perforation, or in a combined position.[1] Surgeon preference plays a part in these decisions and in decisions concerning the technical problems associated with size and location of the perforation and the shape, angle, and bore of the ear canal.

Tympanoplasty successfully closes the tympanic membrane perforation (TMP) in 90-95% of patients. Fortunately, second and third operations succeed in more than 90% of the remaining patients. Consequently, fewer than 1 per 1000 persons still has tympanic membrane perforation (TMP) after 3 operations.

A retrospective study by Carr et al indicated that in adults undergoing myringoplasty (type 1 tympanoplasty), the perforation site affects the success of the procedure, with the closure rate significantly reduced for anterior and subtotal perforations. In the study’s pediatric patients, however, the perforation site appeared to have no such affect.[19]

A study by Tseng et al reported successful subjective and objective outcomes in tympanic perforation repair with endoscopic transcanal myringoplasty. Graft success was achieved by 3 months postoperatively in 87.9% of ears, with the air-bone gap closed to within 20 dB in 86.8% of ears. Pain medication was used for a mean duration of 2.0 days, with the mean pain scale score determined to be 0.1 on the third postoperative day.[24]

Inlay versus underlay surgery

A study by Haksever et al found that inlay butterfly transcanal cartilage tympanoplasty compared favorably with conventional underlay tympanoplasty in patients with dry, perforated chronic otitis media. The investigators examined results from 72 patients, 29 of whom underwent the inlay butterfly cartilage procedure and 43 of whom were treated with conventional underlay surgery. The tympanic-membrane closure rate and audiologic results were similar for the two techniques, but the average duration of surgery for inlay tympanoplasty was about half of that for the other operation (29.9 minutes vs 58.9 minutes, respectively).[20]

Similar results were reported in a study by Kim et al, in which 56 patients underwent inlay butterfly cartilage tympanoplasty, and another 56 individuals were treated with conventional underlay tympanoplasty. Surgical and functional success were comparable between the two procedures, but the duration of the inlay surgery was again about half of that for the underlay technique. Moreover, the visual analogue ̶ scale score for perioperative pain was lower for the inlay operation than it was for the underlay surgery (1.5 vs 4.9, respectively).[21]

A literature review by Jumaily et al found that tympanic membrane perforation closure rates for inlay butterfly transcanal cartilage tympanoplasty ranged from 71-100%. In a separate cohort, of pediatric and adult patients, the investigators reported complete closure in 21 of 32 perforations (66%) repaired with the procedure, with the mean air-bone gap dropping from 13.4 dB to 6.9 dB.[23]

Preoperative Details

Preoperative preparation of the ear for surgery consists of eliminating infection whenever possible. Preoperative preparation of the patient includes convincing the smoker to stop during the immediate postoperative period.

Intraoperative Details

The first known incident of tympanoplasty performed on the wrong ear occurred in 2004. Surgeons are therefore advised to adopt methods similar to those used in other fields, and mark the ear to be operated upon with ink while the patient is awake and able to confirm the accuracy of the selection.

Postoperative Details

Postoperative care is identical for office treatment and operating room repair techniques. Instruct patients to keep water out of their ears. When incisions and ear canal packing are present, use protective dressings, which are commercially available. Otherwise, silicone rubber plugs (also commercially available) or cotton balls waterproofed with a little petroleum jelly suffice.

Follow-up

Risk of cholesteatoma formation, either through the natural course of the disease or from squamous epithelium trapped during treatment, requires regular follow-up care for all patients postoperatively. Several annual visits should be the minimum once tympanic membrane perforation (TMP) healing is verified. Untreated tympanic membrane perforation (TMP) may not require regular follow-up care if a patient can be relied upon to seek medical advice if hearing changes or persistent drainage from the ear is noted. Location of the tympanic membrane perforation (TMP) informs the timing and frequency of follow-up care. Perforations in the pars tensa (stiff portion of the drum) rarely lead to complications.

The exceptions are pars tensa perforations located at the annulus or rim of the tympanic membrane. Tympanic membrane perforations (TMPs) in this location are at risk of developing middle ear cholesteatoma from migration of surface epithelium into the middle ear. Perforations in the pars flaccida (the portion without a fibrous center layer) are more frequently associated with complications and require more frequent follow-up care.

For excellent patient education resources, visit eMedicineHealth's Ear, Nose, and Throat Center. Also, see eMedicineHealth's patient education article Perforated Eardrum.

Complications

Each operation carries a risk of exacerbating hearing loss. Exact incidence of such hearing loss is unclear, with reported rates varying widely in the medical literature. In one series, approximately 1 per 500 operations resulted in much worse hearing. In another, the rate was nearly 2% for some degree of loss. Of 1000 patients, expect one to experience a perforation and 4 to endure lost hearing. In a small group of patients, persistent eustachian tube dysfunction leads to late complications, such as cholesteatoma, reperforation, or middle ear effusion. When the underlay technique of tympanoplasty is used, incidence of intratympanic cholesteatoma is less than 1%.[14] These complications each require unique treatment.

Outcome and Prognosis

Uncomplicated tympanic membrane perforation (TMP) requires no treatment. Perforations remain stable, and prognosis for absence of morbidity is good. Repaired drums reperforate in as many as 10% of patients. Potential for late perforation and the potential for formation of cholesteatoma mandate regular follow-up care for many years after apparently successful surgery.

 

Questions & Answers

Overview

What causes tympanic membrane perforation (TMP)?

What is the clinical presentation of tympanic membrane perforation (TMP)?

How are tympanic membrane perforations (TMPs) diagnosed?

What is the role of screening tympanometry in the diagnosis of tympanic membrane perforation (TMP)?

When is audiometry indicated in tympanic membrane perforation (TMP)?

What is the goal of medical therapy in the treatment of tympanic membrane perforation (TMP)?

What is the first surgical option for the treatment of tympanic membrane perforation (TMP)?

What is the simplest operation for the treatment of tympanic membrane perforation (TMP)?

How is a fat-plug tympanoplasty used to treat tympanic membrane perforation (TMP)?

What is the second surgical option for the treatment of tympanic membrane perforation (TMP)?

What is the incidence of tympanic membrane perforation (TMP)?

What is the main cause of tympanic membrane perforation (TMP)?

Has the decreased use of antibiotics for the treatment of otitis media affected the incidence of tympanic membrane perforation (TMP)?

What is the association between acute otitis media (AOM) and tympanic membrane perforation (TMP)?

Do ear canal infections cause tympanic membrane perforation (TMP)?

What are the traumatic and iatrogenic causes of tympanic membrane perforation (TMP)?

Can a tympanic membrane perforation (TMP) heal spontaneously?

How does cause infection in tympanic membrane perforation (TMP)?

What factors affect the degree of hearing loss in tympanic membrane perforation (TMP)?

What are the signs and symptoms of tympanic membrane perforation (TMP)?

When is treatment indicated in tympanic membrane perforation (TMP)?

What is the anatomy of the tympanic membrane?

What are the 2 zones of the tympanic membrane where perforations can occur?

What is the anatomy of the middle ear relevant to tympanic membrane perforation (TMP)?

What are the contraindications for the treatment of tympanic membrane perforation (TMP)?

Workup

Which imaging studies are used in the workup of tympanic membrane perforation (TMP)?

Which tests are used in the workup of tympanic membrane perforation (TMP)?

Which diagnostic procedure may be indicated in the workup of tympanic membrane perforation (TMP)?

What are the histologic findings in the workup of tympanic membrane perforation (TMP)?

Treatment

What is the medical treatment for tympanic membrane perforation (TMP)?

How can healing time be improved in traumatic tympanic membrane perforation (TMP)?

How effective are systemic antibiotics in the treatment of tympanic membrane perforation (TMP)?

Why does soap increase the risk of infection in tympanic membrane perforation (TMP)?

What are nonsurgical treatment options for tympanic membrane perforation (TMP)?

When are office-based surgical treatments for tympanic membrane perforation (TMP) indicated?

What is the simplest, but least effective surgical method for the treatment of tympanic membrane perforation (TMP)?

How is a fat-plug tympanoplasty performed for the treatment of tympanic membrane perforation (TMP)?

How effective are office-based surgical treatments for tympanic membrane perforation (TMP)?

How effective is a Gelfoam plug in the treatment of tympanic membrane perforation (TMP)?

What is the irritant oil method for the treatment of tympanic membrane perforation (TMP)?

What are the novel office-based surgical treatments for tympanic membrane perforation (TMP)?

What is the role of tympanoplasty in the treatment of tympanic membrane perforation (TMP)?

How do inlay and underlay tympanoplasty compare in the treatment of tympanic membrane perforation (TMP)?

What preoperative preparation is indicated in the surgical treatment of tympanic membrane perforation (TMP)?

How are wrong-site errors prevented in the treatment of tympanic membrane perforation (TMP)?

What is the postoperative care after surgical repair of tympanic membrane perforation (TMP)?

What follow-up care is indicated for patients treated for tympanic membrane perforation (TMP)?

What are the complications of surgical repair of tympanic membrane perforation (TMP)?

What is the prognosis of tympanic membrane perforation (TMP)?