Burst Ear Drum (Burst eardrum) in Children

This article is targeted to parents who have children with middle ear problems.

For  burst eardrum  problems in adults, please click hear

Disease/Disorder Name: Perforation of the Eardrum

ICD-9 Description: Perforation, Central, Tympanic membrane

Description:   Perforation of the eardrum is a rupture of the tympanic membrane. Also called a "Burst Eardrum".

Causes of a burst eardrum

External Causes of a Burst Eardrum

An external cause for a burst eardrum is a head trauma such as a blow to the ear or an object penetrating the ear canal and penetrating the eardrum. An immediate trip to the emergency room is mandatory. The ER nurse or doctor will clean the ear carefully give you an antibiotic shot and antibiotic ear drops, then prescribe antibiotic tablets for a 10 day regimen. In severe cases, you may undergo immediate emergency surgery. For less serious cases, you will be referred to an ENT specialist (Ear, nose, Throat specialist) for outpatient surgery. Depending on the damage, surgery could be minor, or major, where the middle or inner ear components are damaged.

Usually, the larger the perforation, the greater the loss of hearing. The location of the hole (perforation) in the eardrum also effects the degree of hearing loss. If severe trauma (e.g. skull fracture) disrupts the bones in the middle ear which transmit sound or causes injury to the inner ear structures, the loss of hearing maybe quite severe.

With a traumatic or explosive event, the loss of hearing can be great and ringing in the ear (tinnitus) may be severe. In this case the hearing usually returns partially, and the ringing diminishes in a few days.

Side effects of a perforated eardrum (burst eardrum) from external causes will definitely be excruciating pain. You will probably also suffer from vertigo and/or tinnitus until the problem is resolved. However, there have been many cases where, even after healing, vertigo and/or tinnitus persisted.

Internal causes of a Burst Ear Drum

A burst eardrum from internal causes is usually caused by a build-up of bacterial waste from an infection in the middle ear. In the final stages of a middle ear infection, if the pressure becomes too much, and the Eustachian tube is blocked, the eardrum may burst outward. This is actually a positive event if controlled properly. The burst eardrum will immediately relieve the pressure in the middle ear and the accompanying earache will diminish. Your child will stop screaming :)

A smelly discharge (bacteria detritus from the middle ear) will spill out of the ear and can be sopped up with a wet rag or a tissue. Under no circumstances use ear cleaners with a cotton tip to attempt to clean the ear canal past 1/2". Such action may cause irreparable harm to the eardrum!

Symptoms of a pre- Burst Eardrum due to Middle ear Infection (prior to bursting)

Treatment for Burst Eardrum (not for external causes)

The treatment your doctor (family or pediatrician) offers for a burst eardrum will depend on how long your child has had glue ear and the number of prior incidents of glue ear

There are three methods of treatment for burst eardrum from internal causes:

If it is a known viral infection, then the infection should be allowed to run its course as no antibiotics will combat a virus.

Many children recover naturally from a burst eardrum in 2 - 3 weeks (80% +/-). As a parent, self medication can be initially performed on your child by obtaining an OTC (Over The Counter) pediatric oral decongestant to thin the middle ear fluid in the ear and help it drain away. The main purpose of a decongestant is to dry the nasal passages so the Eustachian tube opens and any excess material left in the middle ear drains into the throat.    

If the infection has a known bacterial cause, antibiotics are sometimes prescribed, often initially by injection, then a regimen orally three times a day for at least 7 days.  In children, a penicillin-derivative called amoxicillin or augmentine is often used. Pediazole^® , a brand-name combination of erythromycin and sulfisoxazole can be used if a child is allergic to penicillin or penicillin-derivative products.

****However, before you ask a pediatrician or family doctor for antibiotics, you may want to read the latest from the American Academy of Pediatrics.

Note Also: In the past, antibiotics such as penicillin, erythrosine, or erythromycin were prescribed. However, in the last few decades, many in the general population have become immune to the effects of these antibiotics, and stronger ones are often prescribed. (The cause of immunity is often blamed on antibiotics fed to the food supply (chickens and beef) before they are brought to market. )

Doctors usually adopt a wait-and-see approach to begin with as the torn eardrum often heals over time (3-6 weeks).

These approaches are usually effective for most children. If your child continues to have problems, your doctor may decide to refer them to an ear, nose and throat (ENT) or head and neck surgical specialist.

3. Surgical Treatments for a eardrum that does not close

 If the tear or hole in your eardrum doesn't heal by itself, physical intervention through surgery is performed to close the perforation. Treatments may include:

Myringoplasty (minor surgery)

• There are a variety of surgical techniques to close a hole from a burst ear drum, but basically all procedures attempt to encourage the body to heal the opening so that it eventually seals. Procedures performed through the outer ear canal without any incisions are called Myringotomies. This type of surgery is typically quite successful in closing most perforations permanently. There are two types of surgeons qualified to perform ear drum repair operations: an otolaryngologist or ENT (Ear Nose Throat surgeon), and Head and Neck surgeons.
  
• A myringoplasty is usually done as a day-surgery local or mild general anesthesia basis in about 20 - 30 minutes. The surgeon will "clip" a small patch from under the skin behind the ear. This layer is called the dermis and is still "alive" and will assist with the healing of the ear drum.  With small instruments, the surgeon goes through the ear canal and delicately attach the live skin tissue to the outside of the hole. It will not completely cover the hole so that the body's natural healing function will create new skin growth. Sometimes a surgical glue is used.
  
• Another myringoplasty technique is to add a chemical (usually hyaluronic acid) to the edges of the hole to stimulate growth and instead of live tissue, a thin paper patch is placed on the eardrum to act as a base for skin growth. Several applications of the patch (up to three or four over 3-6 weeks) may be required before the perforation closes completely. If these procedures are just not working, surgery under general anesthesia is usually recommended called a Tympanoplasty.

Tympanoplasty Surgical procedure (major surgery w/ an incision)

A tympanoplasty is performed under general anesthesia in a hospital setting, and lasts 1 - 2 hours.

Photo Courtesy of The Internet Journal of Otorhinolaryngology 

A surgical cut is made behind the ear, through the mastoid area. Then the ear is moved forward to expose the middle ear cavity, the back of the eardrum and the front edge of the eardrum. The eardrum is cleaned and the infected area (if any) is cut away.

The edges of a portion of the eardrum are cut away so the back of the eardrum can be accessed. An instrument holds the resultant flap back while a graft is affixed to the back of the eardrum. Hole in the Eardrum

As with a myringotomy, a piece of tissue from large enough to cover most of the hole (a graft), is usually taken from behind the ear and grafted onto the back of the eardrum.

One technique utilizes a foam gel that is inserted into the middle ear cavity to act as a platform for the graft and to keep the ear drum as still as possible. The graft is inserted into the inside of the eardrum where the edges of the hole are folded back onto the perforation to close the hole. The eardrum and graft rest on the foam gel. Surgical glue may be applied to keep the tissue in place as it heals. After a few weeks the foam gel is beaks down and is discharged out through the Eustachian tube. The surgical glue is also gradually sloughed off as the tissue heals.

The Healing Process After a Tympanoplasty

At the end of surgery, the ear will be fitted with a hard cover like an ear muff to protect it while it heals. It can be safely removed in a few days. There will be sutures behind the ear from the surgery usually covered by steri-strips or tape which need to be kept on for about two weeks. Hearing in the affected ear will be limited as there is packing in the ear canal. As the skin behind the ear heals, it will get itchy, so don't scratch :).  After a couple weeks the sutures will be removed. The packing in the ear will also be removed either at the two week follow-up or a few weeks later. The eardrum should be healed after 4-6 weeks from the surgery.

 

Tympanoplasty example

Photo Courtesy www.nursing4all.com