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BackTable / ENT / Article
Pediatric Tympanic Membrane Perforation: Operative & Non-Operative Management
Julia Casazza • Updated Jan 17, 2024 • 60 hits
Tympanic membrane perforations occur frequently in younger children. While most will eventually heal on their own, persistent perforations can predispose affected individuals to chronic ear disease and hearing loss. Understanding when to operate can help avoid these complications. Expert otologists Dr. Walter Kutz of UT Southwestern and Dr. Daniel Choo of Cincinnati Children’s Hospital recently sat down with Backtable ENT to share their practice philosophies on this common problem.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Children with tympanic membrane perforations may have a history of ear tubes, chronic draining ears, or eardrum trauma.
• When examining a tympanic membrane perforation, otoscope exam frequently suffices, but a flexible scope placed in the ear can provide better resolution. Avoid using rigid endoscopes, as these can be painful to the patient when manipulated in the ear canal.
• A child with cholesteatoma, chronic otorrhea, or significant hearing loss resulting from tympanic membrane perforation should undergo tympanoplasty. Absent these symptoms, most patients can be monitored.
• Children who do not undergo surgery for their perforation but experience hearing loss can benefit from preferential seating in school, frequency modulation (FM) systems, and hearing aids. Bone-anchored hearing aids (BAHAs) are particularly helpful for conductive hearing loss.
Table of Contents
(1) Causes of Tympanic Membrane Perforation in Children
(2) Determining When Surgery is Necessary in Tympanic Membrane Perforation
(3) Non-Operative Management of Pediatric Tympanic Membrane Perforation
Causes of Tympanic Membrane Perforation in Children
Pediatric patients with tympanic membrane perforations usually fall into one of three groups: (1) the child previously with tympanostomy tubes who now has a dry perforation, (2) the child with a chronic draining ear, and (3) the child with a traumatic perforation (much less common). Etiology affects subsequent management; patients with only mild hearing loss, no cholesteatoma, and no ear drainage can usually be monitored, whereas those with more troublesome symptoms may need tympanoplasty. When examining the child, a standard otoscope will usually suffice, but if closer detail is desired, a flexible scope can be placed in the ear canal to visualize.
[Dr. Daniel Choo]
They seem to come in different phases. I'll get my three, four, five-year-old kids who've had one or multiple sets of tubes in their earlier lives and then as the tubes fell out, they're left with a residual perforation mixed in there but overlapping in that Venn diagram. Then you got these kids who just developed these chronic suppurative ears that just drain and they always have a perforation and seem to manage those with and without tubes and you end up at this place where they've got holes in their eardrums. Then a smaller proportion are those kids who come back later either from a traumatic or maybe they had just had a fluke acute otitis episode that perforated and they come in with these clean, dry, very sclerotic-looking perforations. Each of those you manage obviously just a little bit differently.
[Dr. Walter Kutz]
Yes, it's pretty similar in my practice. Sometimes a child may not have any early symptoms and they get their first hearing screening in school. They notice they have a little hearing loss, you come to see them, they have a dry perforation which I think a lot of times is probably from a tympanostomy tube that extruded and they have a persistent perforation.
[Dr. Gopi Shah]
I usually will ask any history of drainage, how's their speech, how are they doing in school. What other things on the history are you all asking or do you always have on your checklist of questions?
[Dr. Walter Kutz]
I like to ask about have they had a history with tympanostomy tubes. I think it's very important. A lot of these kids, if they don't have a cholesteatoma, they don't really have drainage, they have a mild hearing loss, we're going to follow them for a while. If they're really struggling in school, perhaps that may be more incentive to repair the perforation or at least consider a hearing aid. I think asking about cleft palate, does the child have other craniofacial abnormalities, allergy problems, these sort of things are really important. Also, I think asking about the contralateral ear is important. Are they continuing to get infections in their contralateral ear? I'd be less likely to offer a tympanoplasty in that situation.
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Determining When Surgery is Necessary in Tympanic Membrane Perforation
Children with craniofacial abnormalities (including those seen in trisomy 21 and cleft lip/palate) are at higher risk for tympanic membrane perforation due to their unique anatomy. Not all children need surgery for their perforation, as most will heal over time. Dr. Kutz recommends fixing a perforation when associated with one or more of the following: cholesteatoma, chronic otorrhea, or significant hearing loss. Patients with “dry” perforations (meaning that there is no fluid drainage from the ear) can be monitored at routine follow-up visits and fitted for hearing aids as appropriate.
[Dr. Gopi Shah]
You had mentioned some of the risk factors underlying eustachian tube dysfunction from craniofacial like cleft palate. We do have a special group of whether it's syndromic, non-syndromic, cleft palate, or children with trisomy 21, eustachian tube dysfunction that can end up with residual perfs or get a perf that doesn't heal, and so forth. How do you think about those kids? How does that underlying risk factor play a role into your decision-making of how to manage?
[Dr. Walter Kutz]
Yes, I think I'm more likely to follow those perforations, especially if they're not causing really any issues. If they're a small perforation, and they're dry, there's no cholesteatoma, hearing's still good, it's basically acting like a tympanostomy tube, which a lot of these kids are going to need anyway. Now, saying that, my overall big three criteria to fix a perforation would be if there is evidence of a cholesteatoma, if they have chronic otorrhea that they're on multiple sets of ototopical drops, and maybe sometimes they get a lot of oral antibiotics from their pediatrician, and then if they have really significant hearing loss. Those are the kids I would typically address, but a kid with a cleft palate, other syndromic issues, higher risk of eustachian dysfunction, oftentimes I'll try to follow them as long as I can, and a lot of times, even if it's some hearing loss, they can wear a hearing aid pretty successfully.
[Dr. Daniel Choo]
I'm on the same page. There's different points in my career where I felt like, "oh, I can close that one, that'll be all right," and you get burned a few times and say, "All right, I need to dial that back a little bit." It's rare that I've been disappointed that I waited longer. There's extremely rare instances where a very benign-looking perf ends up developing some squame growing into the middle ear, and I said, "oh, I should have gone back in before that developed," but that's a pretty rare exception, I think. I'm more sensitized, and I don't know if it's from living in the Ohio River Valley, but the environmental allergy stuff, rhinosinusitis with associated eustachian tube dysfunction, it was a real bugaboo for me. There's kids where we patched them up successfully, but then they come back with recurrent fluid, and you end up poking a hole back through with a tube in a drum that you just repaired, and you feel like, "Ugh, why did I do that?" We're cautious about those for sure these days.
[Dr. Gopi Shah]
Do you try to get them evaluated for allergy, put them on medication? How do you manage that part of it or consult?
[Dr. Daniel Choo]
If I'm suspicious about that, certainly starting on history and physical, we'll try and probe it and see if there's a family history of environmental allergies, which I think is a risk factor, take a quick look in their nose, see if their turbs are really swollen, chronically congested. I'll usually start putting them on an antihistamine and some Flonase-type stuff, but if they still have symptoms after that, then that's when I'll usually refer them on for a formal allergy testing. The frustrating one is where it comes back all negative, and you and the family are saying, "I know my kid has allergies." I wish it had shown positive, and we'd figure out what to treat more targeted fashion.
Non-Operative Management of Pediatric Tympanic Membrane Perforation
While most patients who undergo tympanoplasty experience a dramatic improvement in their hearing, a small minority do not. Further, some families may choose non-operative management based on other medical needs or concerns. Children with hearing loss can benefit from preferential seating, hearing aids, and frequency modulation (FM) systems. Hearing aid options include traditional over-the-ear aids and bone anchored hearing aids (BAHA), the latter of which are particularly effective for conductive hearing loss. FM systems allow direct transmission from a microphone (worn by a teacher) to a child’s hearing aid.
[Dr. Gopi Shah]
Then quickly, in terms of hearing rehab options for the child that we didn't repair or the child that had the same or worse hearing outcome after surgery, audiology visit, hearing aid, preferential seating. Tell me, FM systems.
[Dr. Walter Kutz]
I think all those. You definitely want to document things and talk to the parents about preferential seating. Let's say they have a unilateral mild, moderate hearing loss, if they're kids in Texas, Medicaid, they're not going to be able to get a hearing aid. It may not be worth that much money just to buy a hearing aid, but, an FM system can really solve those issues in school at least and help learning. One thing, if you don't fix a perforation, most kids can tolerate a hearing aid, but there's a chance the moisture retention that they're going to get chronic otorrhea. I leave that to the parents. If they have bilateral, moderate, severe hearing loss, those kids really probably should be encouraged to wear hearing aids. Also can't forget the bone-anchored hearing devices.
The new transcutaneous devices, we've had really good success. I've converted a number of patients from the percutaneous to the new transcutaneous, and they really like the sound quality better, probably gives a little better high-frequency hearing. Now they don't have this poll sticking out of their scalp. They just put on a magnet and they can use it with their phone and everything else. That's another option that can be considered, but you don't want to forget about the hearing component, obviously. If a kid or a patient has bilateral cholesteatoma, terrible hearing, a lot of times the first surgery, I'll just put in a percutaneous bone-anchored hearing aid, because they may have hearing problems for two or three years. By the time you operate on one ear, do a second look, if you do a second look, so the other ear second look, and you may not get a good hearing result.
I think putting a bone-anchored hearing aid as soon as you can will at least give them-- you're going to solve the hearing issue until you get this all fixed. That's something to think about.
Podcast Contributors
Dr. Daniel Choo
Dr. Daniel Choo is the director of Pediatric Otolaryngology - Head and Neck Surgery with Cincinnati Children’s Hospital in Ohio.
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, March 30). Ep. 100 – Tympanic Membrane Perforation in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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