Middle Ear, Tympanic Membrane, Perforations Workup

Updated: May 07, 2020
  • Author: Matthew L Howard, MD, JD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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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.