65-year-old with a History of Diving

A 65-year-old gentleman presented for evaluation of an unrelated complaint. He reported a long history of “ear issues” that began when he was in the Navy. He was followed by ENT, but had not been seen in their clinic for several years. He denied new complaints or hearing concerns. His Wispr digital otoscopic exam is shown.

Which of the following is true regarding his tympanic membrane (TM)?

A. The most common cause in children is from recurrent acute otitis media (AOM)
B. The most common cause in adults is from trauma
C. The lesion is most likely to occur in the pars tensa
D. All of the above

The TM demonstrates a perforation in the anterior portion of the pars tensa. As the largest and thinnest area of the TM, it is the most common site of perforations. In children, recurrent AOM is the leading etiology, followed by post tympanostomy tube non-healing. In adults and older children, blunt injury is more common, with Q-tip insertion often the culprit.  Noises louder than 150 decibels (firework blasts) and barotrauma from scuba diving (notably, this individual was a Navy diver) are also known to result in perforation.

The prognosis for TM perforation is generally favorable, as the majority heal on their own within 4 to 6 weeks under instructions to keep the auditory canal dry. However, delayed or non-closure may occur in large perforations, if secondary infection sets in, or when injury occurs in the posterior superior quadrant.  In these instances, prompt evaluation by an otolaryngologist (ENT) is indicated to guide next steps in management.

Key Learning Points:

1. TM perforations in children are most often caused by recurrent AOM
2. TM perforations in adults are most often caused by trauma