Abstract
Objective
The purposes of this study were to determine the factors involved in the spontaneous healing and to profile the various etiologies of traumatic tympanic membrane (TM) perforation.
Methods
A retrospective review was performed on 729 cases of traumatic TM perforation diagnosed in the emergency department and outpatient clinic from January 2007 to March 2011.
Results
A total 641 patients with traumatic TM perforations were enrolled in the study. The group consisted of 320 male and 321 female patients with a mean age of 33.6 years (3–79 years). The types of trauma included compression injury (554 patients), blast injury (55 patients), and instrumental injury (32 patients). The causes of conflict by a slap or a fist were spouse or lover (52%), parents and sibling (3%), school teachers (4%), schoolmate (12%), state police and prisoner (7%), and blow against the ear during street fight (22%). Of the 641, 137 were lost during follow-up; of the remaining 504, perforations closed spontaneously in 451 (89%), within a mean of 27.4 days. Wet perforations with bloody or watery discharge significantly improved the healing rate ( P < .01) and shortened the average perforation closure time ( P < .01), as compared with dry perforations. Although the perforation that involved malleus or umbo damage did not significantly affect the healing rate ( P > .05), a significantly prolonged closure time (41.6 vs 23.8 days) was observed as compared with no damage. However, the curled edges did not also affect the outcome of spontaneous healing; the healing rate was 91% and 88% ( P > .05), and the average closure time was 28.1 and 26.7 days ( P > .05), respectively, for with and without curler edges. By perforation size, the overall healing rate was 92% and 54% ( P < .01), and the average closure time was 22.8 and 47.3 days ( P < .01), respectively, for small and larger perforations. Moreover, 7 patients had neomembrane formation on follow-up, 2 developed cholesteatoma, 1 developed tympanosclerosis, and 1 developed facial paralysis.
Conclusion
In our experience, domestic violence and street fight were the most common causes of the traumatic TM perforation. Traumatic TM perforations have excellent prognosis. However, preexisting tympanosclerosis and the perforation that involved malleus or umbo damage could lengthen the healing time of perforation, Wet perforations with bloody or watery discharge accelerate the healing, but the curled edges did not affect the outcome of spontaneous healing.
1
Introduction
The tympanic membrane (TM), or the eardrum, separates the external ear from the middle ear and perceives sound and sends the information to the brain. As a thin sheet, the eardrum is highly sensitive to air pressure changes in external auditory canal. Whether in wartime or in peacetime, traumatic TM perforation was always seen in otologic trauma. Blast injuries were caused by explosive blasts in wartime or terrorist explosive blast activities, and nonexplosive blast injuries in peacetime (eg, slap against the ear, barotrauma, and instrumental injury) were occasionally caused by New Year’s firecrackers and fireworks ; previous study have suggested that the mechanism of nonexplosive blast injury is similar to explosive blast. However, various factors have proven to positively or negatively affect an individual’s susceptibility to TM rupture. Studies have demonstrated that disease or previous injury, increased age, inadequate pneumatization, and TM position perpendicular to the incident wave all increase the likelihood of perforation. Moreover, previous study also shows that the sources of slaps are different between various regions; Afolabi et al and Orji reported that security agents and the state police were the main aggressors.
Investigators have demonstrated that up to 80% of all perforated TMs heal spontaneously, with relatively few requiring operative intervention . Large size of perforation and peripheral location of the defect have both been associated with lower rates of spontaneous healing . The curled edges may delay healing and even increase the likelihood of middle ear cholesteatoma ; secondary discharge often fails to close spontaneously . Furthermore, most patients, in previous studies, were reported to be asymptomatic or presented with subjective hearing loss and tinnitus .
In this study, we recruited a relatively large patient sample to carry out a retrospective study of traumatic TM perforation according to different injury types, age and sex distribution, and relationship between size of perforation, degree of hearing loss, and the various factors influencing spontaneous healing of traumatic TM perforation.
2
Materials and methods
This is a retrospective review of 729 patients with traumatic TM perforation seen at the ear, nose, and throat clinic and emergency department of The Affiliated Yiwu Hospital of Wenzhou Medical College, Zhejiang Province, China, between January 2007 and March 2011 from various causes, for example, a slap against the ear or a blow by the fist, sport accidents, kiss ear, blast injury, penetrating injury through external auditory canal, and others. However, these patients with multiple traumas resulting from burn accident, road traffic accident, and falling from a high place were excluded from the study. This study was discussed and approved by the Institutional Ethics Committee of The Affiliated Yiwu Hospital of Wenzhou Medical College.
The data retrieved included the following parameters: sex, age, side, cause of injury, and symptoms such as earache, hearing loss, tinnitus, and vertigo were recorded. The eardrum appearance was assessed by endoscope. The following criteria were used to estimate the relative size of the perforations: small perforation, less than one half of the TM, and large perforation, at least one half of the TM. Standard pure-tone audiometric testing was performed. Pure-tone averages were determined for air and bone conductions at 500, 1000, 2000, and 4000 Hz.
A conservative management approach was adopted, except for those with bloody or watery discharge who received oral systemic antibiotics to prevent infection. However, for those with existing purulent ear discharge, the middle ear infections were treated with appropriate systemic ear drops, and the ears were subsequently kept dry. Follow-up visits were scheduled. During these visits, an inquiry was made into the clinical course, or within at least 3 months, the eardrums were examined endoscopically and findings were recorded. The patients were advised not to wet the ears and to antedate their appointments if discharge appeared. The assessment of follow-up visits was recorded at least 3 times for every patient.
2.1
Statistical analyses
The data retrieved included the biodata, the clinical presentation, source of injury, the clinical findings, and the outcome of the patients, which were entered into SPSS version 11.0 software (Chicago, IL). Data on healing rate, complete closure time, pure-tone audiometric results, and air-bone gap were analyzed by paired t test and analysis of variance. Differences were considered significant when P < .05.
2
Materials and methods
This is a retrospective review of 729 patients with traumatic TM perforation seen at the ear, nose, and throat clinic and emergency department of The Affiliated Yiwu Hospital of Wenzhou Medical College, Zhejiang Province, China, between January 2007 and March 2011 from various causes, for example, a slap against the ear or a blow by the fist, sport accidents, kiss ear, blast injury, penetrating injury through external auditory canal, and others. However, these patients with multiple traumas resulting from burn accident, road traffic accident, and falling from a high place were excluded from the study. This study was discussed and approved by the Institutional Ethics Committee of The Affiliated Yiwu Hospital of Wenzhou Medical College.
The data retrieved included the following parameters: sex, age, side, cause of injury, and symptoms such as earache, hearing loss, tinnitus, and vertigo were recorded. The eardrum appearance was assessed by endoscope. The following criteria were used to estimate the relative size of the perforations: small perforation, less than one half of the TM, and large perforation, at least one half of the TM. Standard pure-tone audiometric testing was performed. Pure-tone averages were determined for air and bone conductions at 500, 1000, 2000, and 4000 Hz.
A conservative management approach was adopted, except for those with bloody or watery discharge who received oral systemic antibiotics to prevent infection. However, for those with existing purulent ear discharge, the middle ear infections were treated with appropriate systemic ear drops, and the ears were subsequently kept dry. Follow-up visits were scheduled. During these visits, an inquiry was made into the clinical course, or within at least 3 months, the eardrums were examined endoscopically and findings were recorded. The patients were advised not to wet the ears and to antedate their appointments if discharge appeared. The assessment of follow-up visits was recorded at least 3 times for every patient.
2.1
Statistical analyses
The data retrieved included the biodata, the clinical presentation, source of injury, the clinical findings, and the outcome of the patients, which were entered into SPSS version 11.0 software (Chicago, IL). Data on healing rate, complete closure time, pure-tone audiometric results, and air-bone gap were analyzed by paired t test and analysis of variance. Differences were considered significant when P < .05.
3
Results
3.1
General data
A total of 729 patients were found to have traumatic TM perforation; however, 88 were excluded because of incomplete data and multiple traumas. Thus, only 641 were enrolled in the study. The group consisted of 320 males and 321 females. Their age ranged from 3 to 79 years, with a mean age of 33.6 years. The right ear was involved in 173 patients, and the left, in 468 patients.
A total of 641 patients were divided into 3 groups according to the cause of injury: blast injury group, barotrauma group, and penetrating injury group. The barotrauma group was again divided into 2 subgroups depending on the cause of injury: slap injury group and nonslap injury group (eg, kiss ear, ball sport, snow sport, etc) ( Tables 1, 2 , and 3 ). The incidence of trauma was significantly different between both ears and sex ( P < .01). Moreover, the incidence of larger perforation was 67% in the blast injury group, significantly higher ( P < .01) than that in the barotrauma group (16%). In the slap injury group (age range, 7–79 years), 2% of them were 10 years or younger; 79%, between 21 and 40 years; and 10%, 40 years and older. However, in the blast injury group (age range, 18–57 years), no one was 10 years or younger, 20% were between 21 and 40 years, and 78% were 40 years and older. The distribution of ages was significantly different between 2 groups ( P < .01), but 60% of them were 10 years or younger in the penetrating injury group.
| Etiology | No. of ears | Frequency (%) | Left ear, n (%) | Right ear, n (%) | Male, n (%) | Female, n (%) |
|---|---|---|---|---|---|---|
| Slap injury | 502 | 78.4 | 419 (83) | 83 (17) | 197 (39) | 305 (61) |
| Blast injury | 55 | 8.6 | 11 (20) | 44 (80) | 52 (95) | 3 (5) |
| Instrumental injury | 32 | 5.0 | 5 (16) | 27 (84) | 31 (97) | 1 (3) |
| Sport injury | 36 | 5.5 | 27 (75) | 9 (25) | 29 (81) | 7 (19) |
| Pushing canal | 14 | 2.2 | 6 (43) | 8 (57) | 11 (79) | 3 (21) |
| Kiss ear | 2 | 0.3 | 0 (0) | 2 (100) | 0 (0) | 2 (100) |
| Total | 641 | 100.0 | 468 (73) | 173 (27) | 320 (50) | 321 (50) |
| Etiology | No. of ears | Small, n (%) | Large, n (%) |
|---|---|---|---|
| Blast injury | 55 | 18 (33) | 37 (67) |
| Barotrauma | 554 | 464 (84) | 90 (16) |
| Instrumental injury | 32 | 29 (91) | 3 (9) |
| Total | 641 | 511 (80) | 130 (20) |
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