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🦻 Tympanic Membrane Perforation & Grommets:: MSRA MCQs quiz

Updated: Jul 21

🔹 1. Causes of TM Perforation (Aetiology)

Mnemonic: 5 W’s

  • Wear – Foreign body (e.g. Q-tip, hairpin)

  • Whit – Spontaneous rupture (e.g. barotrauma)

  • War – Trauma (e.g. slap, punch, blast injury)

  • Water – Infection (Acute Otitis Media)

  • Wobble – Iatrogenic injury (suction, instrumentation)


🔹 2. Clinical Features

Feature

Description

Hearing loss

Sudden, often conductive

Otorrhea

Clear or serous initially; purulent if infected

Ear pain

May be present if due to infection or trauma

Tinnitus

Ringing or buzzing

Fever

Suggests infective cause (e.g. AOM)

Itching

May occur if chronic or fungal involvement


🔹 3. Examination Findings


▪️ Tuning Fork Tests

  • Rinne: Negative (Bone > Air) on affected side → Conductive loss

  • Weber: Lateralises to affected side → Conductive loss


▪️ Otoscopy

  • TM perforation: Central defect, absent light reflex

  • Glue ear: Retracted, dull drum with air-fluid level


🔹 4. Audiology & Tympanometry

  • Glue ear (OME): Conductive hearing loss + Type B tympanogram (flat)

  • Normal: Type A tympanogram

  • Eustachian tube dysfunction: Type C tympanogram (negative pressure)



🔹 5. Management


✅ Conservative (Most cases)

  • Keep ear dry (avoid swimming, water entry)

  • No Q-tips or probing

  • Spontaneous healing in 2–4 weeks (especially traumatic perforations)


✅ Treat Infection if Present

  • Use non-ototoxic drops: Ofloxacin or Ciprofloxacin

  • Avoid aminoglycosides (e.g. gentamicin, neomycin, framycetin) if TM is perforated or if grommet is in place


✅ Persistent Perforation

  • 8 weeks: Refer to ENT for myringoplasty



🔹 6. Grommet Insertion (Tympanostomy Tubes)


🔸 Indication (NICE Criteria)

  • Bilateral otitis media with effusion (OME) lasting >3 monthsAND

  • Hearing loss ≥25–30 dB


🔸 Function

  • Equalises pressure

  • Drains fluid from middle ear

  • Improves hearing and speech development


🔸 Post-Insertion Advice

  • Ear protection during swimming (if advised)

  • Air travel is safe — grommets allow pressure equalisation


🔸 Follow-Up

  • Routine ENT follow-up

  • Grommets usually fall out in 6–12 months

  • If TM fails to close → ENT reassessment for perforation


🔹 7. Complications

Condition

Complication

TM perforation

Chronic suppurative otitis media, hearing loss

Grommet insertion

Persistent perforation, otorrhea, tympanosclerosis (scarring)

Glue ear

Speech delay, learning difficulties


🔹 8. Key Safety Points

  • Never prescribe ototoxic drops if TM is perforated or grommet is present

  • ENT referral needed for:

    • Persistent perforation

    • Recurrent OME with hearing loss

    • Suspected cholesteatoma (foul discharge + granulation + hearing loss)


🔹 9. Paediatric Considerations

  • Glue ear (OME) is the most common cause of hearing loss in children

  • Key features: dull drum, fluid level, speech delay

  • Always refer to audiology if hearing loss is suspected

  • Treat conservatively unless criteria for grommets are met


📚 References

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