Allow me to introduce myself. I am Michael Rensink, a practicing ENT specialist for over 35 years. This month I have the pleasure of introducing a new column in The Hearing Journal, Through the Otoscope, which will offer a photographic study of the ear.
Michael J. Rensink, MD, is a member of ENT Associates of San Diego and has been a practicing ENT specialist for over 35 years.
Most professionals are able to observe a tympanic membrane perforation using a standard otoscope. However, it may be difficult to notice the difference between a healed perforation and an open perforation. A helpful hint on figuring out the difference between the two would be to use a pneumatic otoscope. When positive and negative air pressure is applied to the ear with this type of otoscope, it allows you to move the membrane tissues.
Tympanographic studies are also useful in differentiating a perforated ear. The normal pup-tent shaped curve denotes the mobility of an intact tympanic membrane. This shape disappears when the drum is perforated and becomes a flat trace. The relative volume measurements, done during the tympanogram, provide helpful information. The relative volume value for a non-perforated ear is small, about 1.00 ml. This value often jumps to over 2.00 ml when the membrane is open. It is critically important that anyone who works with a perforated ear is extremely cautious.
When doing an impression of the ear for hearing aids it is crucial to understand the sensitivity of this area. It is possible to inflict severe damage to an ear if the ear mold impression material is accidently injected into the middle ear through the perforation in the ear drum. When such an impression is removed, the trauma to the ear can be substantial and irreversible, i.e. a total loss of hearing in that ear.
Part of my treatment program for patients who have chronic ear problems and/or eardrum perforations, is to have the patient keep the ear completely dry. A “water plug” made for this type of ear is usually helpful. Continued treatment by an otolaryngologist is also needed.
Let's study the photographs: Which of these two figures is the “healed” perforation? Can you see the difference between the open membrane and the closed one? The patient with the “healed” perforation was referred to me by her primary doctor to “treat” the ear for the perforation. That particular doctor was not aware that the eardrum had healed itself (a thin translucent membrane covers the opening).
If you look at both of these ears with a standard fiber optic otoscope, they look extremely similar. However, the use of a pneumatic otoscope with applied air pressure to the ear drum will easily distinguish between the healed and non-healed perforation.
If you look carefully at Figure 1 you can see the cone of light reflecting off of the healed tissue. You can also see small bright red blood vessels along the right edge of the perforation. The normal (older) part of the drum is almost a cloudy milky color. The new tissue is clear, clean, shinny, almost translucent. If you look carefully at the new tissue you can see tiny blood vessels running through the surface of the skin.
In contrast, the perforation zone in Figure 2 is simply an opening. The cone of light is missing and there is no tissue over the opening. A bit of cerumen residue and other debris from the ear canal are seen on the lower right hand quadrant. This lady had questions about her ear, and the photograph was helpful in showing her the importance of keeping water out of it.
When a person has a healthy ear and the tympanic membrane tissues are “strong,” the use of over-the-counter medications for cleaning the ears may be useful. In contrast, when a patient has a perforated ear, professionals must be careful in recommending any type of over-the-counter medications, as these can end up in the middle ear and mastoid cavity and inflame the tissue.
Infections in the mastoid cavity are serious and must be avoided. If you have patients with perforated eardrums, I suggest you put a “red flag” into the patient's chart so that whenever you interact with the patient you will not unwittingly make inappropriate recommendations.