Background: Traumatic perforation of the tympanic membrane may be due to direct or indirect

source. The aim of the study is to profile the various aetiologies of traumatic tympanic membrane

perforation in Ilorin, north central Nigeria.

A retrospective review of 64 patients seen at the University of Ilorin Teaching hospital, Ilorin,

Nigeria over a ten year period (January 1998 to Dec 2007) with history of traumatic tympanic

membrane perforation from various causes, these also included multiply injured patients with

bleeding from middle ear as part of their presentations. The data retrieved included the biodata,

the clinical presentations, source of injury, the clinical findings and the treatment outcome. The data

were entered into an SPSS version 11 computer soft ware and analyzed descriptively.

Findings: Sixty four (64) ears were analysed, Age range 6 months to 50 yrs, mean age of 29.2 yrs

7.9% of them were ≤5 years, 29.7% between 21-34 years, and 37.7% were 35 years and above. The

male to female ratio was 2.5:1.0. Commonest aetiology was from slaps, then road traffic injury (RTI)

in 35.9% and 23.5%, Majority of the slap injury were from fights (30.5%), security agents, senior

students and cultists at schools (17.4% each). Sudden hearing loss was a typical presentation

(95.3%), majority of the patient defaulted from follow up once the symptoms of bleeding and pain

subsided. Only 7.8% had neomembrane formation on follow up

Conclusion: Traumatic perforation of the tympanic membrane is an uncommon injury that is

under-reported, there is the need to educate on alternative punitive measure among students and

security agents, unskilled removal of foreign body, early identification, evaluation and referral of

patients reduces the attendant morbidit

Afolabi, Olushola A

Alabi, Biodun S

Aremu, Shuaib K

Segun-Busari, S

Afe Babalola University Repository

BioMed CentralBMC Research NotesssOpen AcceShort ReportTraumatic Tympanic Membrane perforation: An aetiological profileOlushola A Afolabi*, Shuaib K Aremu, Biodun S Alabi and S Segun-BusariAddress: University of Ilorin/University of Ilorin Teaching Hospital, PO Box 931, Ilorin, NigeriaEmail: Olushola A Afolabi* - droaafolabi@yahoo.com; Shuaib K Aremu - skaremu2002@yahoo.com; Biodun S Alabi - alabibs@yahoo.com; S Segun-Busari - segunsegunbusari@yahoo.com* Corresponding author    AbstractBackground: Traumatic perforation of the tympanic membrane may be due to direct or indirectsource. The aim of the study is to profile the various aetiologies of traumatic tympanic membraneperforation in Ilorin, north central Nigeria.A retrospective review of 64 patients seen at the University of Ilorin Teaching hospital, Ilorin,Nigeria over a ten year period (January 1998 to Dec 2007) with history of traumatic tympanicmembrane perforation from various causes, these also included multiply injured patients withbleeding from middle ear as part of their presentations. The data retrieved included the biodata,the clinical presentations, source of injury, the clinical findings and the treatment outcome. The datawere entered into an SPSS version 11 computer soft ware and analyzed descriptively.Findings: Sixty four (64) ears were analysed, Age range 6 months to 50 yrs, mean age of 29.2 yrs7.9% of them were ≤5 years, 29.7% between 21-34 years, and 37.7% were 35 years and above. Themale to female ratio was 2.5:1.0. Commonest aetiology was from slaps, then road traffic injury (RTI)in 35.9% and 23.5%, Majority of the slap injury were from fights (30.5%), security agents, seniorstudents and cultists at schools (17.4% each). Sudden hearing loss was a typical presentation(95.3%), majority of the patient defaulted from follow up once the symptoms of bleeding and painsubsided. Only 7.8% had neomembrane formation on follow upConclusion: Traumatic perforation of the tympanic membrane is an uncommon injury that isunder-reported, there is the need to educate on alternative punitive measure among students andsecurity agents, unskilled removal of foreign body, early identification, evaluation and referral ofpatients reduces the attendant morbidity.BackgroundTrauma generally is blight on our society and it is a majorcause of morbidity and mortality in any society [1]. Thiscould be in form of assaults, road traffic injury, domestic,industrial and sports injuries. These are relatively on theincrease in our society although it is difficult to know theeconomic impact on Nigeria, however it is estimated thatthe annual cost of dealing with this tragedy is more than$100 billion in the USA.In a 1999 study, it was found that the average personalinjury in the workplace costs more than $8,000 in lostPublished: 21 November 2009BMC Research Notes 2009, 2:232 doi:10.1186/1756-0500-2-232Received: 5 August 2009Accepted: 21 November 2009This article is available from: http://www.biomedcentral.com/1756-0500/2/232© 2009 Afolabi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4(page number not for citation purposes)BMC Research Notes 2009, 2:232 http://www.biomedcentral.com/1756-0500/2/232earnings [2]. Trauma patients consume more health careresources than heart and cancer patients combined, andwhereas mortality from heart disease and cancer is declin-ing, the incidence from trauma is increasing [3,4].Trauma to the ear could be simple blunt trauma to thepinna; laceration of the pinna avulsion of part or thewhole of the pinna; uncomplicated tympanic membraneperforation; dislocation of the ossicles; longitudinal andtransverse fractures of the petrous temporal bone withassociated loss of inner ear and facial nerve function [5-11]Trauma to the tympanic membrane and the middle earcan be caused by overpressure (slap, fight, assault fromsecurity agents and road traffic injury (RTI)), thermal orcaustic burns, blunt or penetrating injuries such as instru-mentations and barotraumas [12,13]. Overpressure is byfar the most common mechanism of trauma to the tym-panic membrane [12]. Traumatic perforation of the tym-panic membrane may be caused by direct impact of fluidsand direct pressure from outside. The aim of the study isto profile the various aetiologies of traumatic tympanicmembrane perforationMethodsThis is a retrospective review of 64 patients seen at the Ear,Nose and Throat clinic and the accident and emergencyunit of the University of Ilorin Teaching hospital, Ilorin,Nigeria over a ten year period between January 1998 toDec 2007 with history of bleeding from the ear due totrauma from various causes, also included were patientswith multiple trauma who also had traumatic tympanicmembrane perforation as part of the presentation. Thedata retrieved included the biodata, the clinical presenta-tion, source of injury, the clinical findings and the out-come of the patients were entered into an SPSS version11.0 computer soft ware and analyzed descriptively.ResultsSeventy patients (70) were found to have traumatic tym-panic membrane perforation however 6 were excludedbecause of incomplete data thus only 64 were analyzedand formed the basis for this study. Age range 6 monthsto 50 yrs with a mean age of 29.2 yrs and modal age of 35years. About 5 (7.9%) of them were ≤5 years and majorityof the patients were between 35 and 50 years of age Table1. There are 46 (71.9%) males and 18(28.1%) femaleswith a male to female ratio of 2.5:1 and cross tabulationand predisposition male were mostly affected in most ofthe aetiologies except in fall where no male was recordedtable 2The commonest aetiology recorded was from slaps, thenroad traffic injury (RTI) in 35.9% and 23.5% respectivelytable 3Majority of the slap injury were from fights, securityagents, senior students and cultists at schools in 30.5%,17.4% and 17.4% respectively (Table 4).Traumatic tympanic membrane perforation showed that36 left ears and 28 right ears were affected.Majority of the patients (95%) had associated suddenhearing loss, tinnitus in 52% while 24 (37.5%) of thepatient had progression to chronic suppurative otitismedia (Table 5) and it was observed that majority of thepatient defaulted from the follow up once the symptomsof bleeding and pain subsided mostly after an average ofthree follow up visits. Out of the few that came for followup only 7.8% had neomembrane formation.DiscussionThe tympanic membrane (TM) is an important compo-nent of sound conduction as its vibratory characteristic isnecessary for sound transmission in human beings [14].Trauma to TM and the middle ear can be caused by over-pressure, thermal or caustic burns, blunt or penetratinginjuries, and barotraumas [12,13]. Overpressure is by farthe most common mechanism of trauma to the TM in ourstudy similar to various studies else where [5,12,13].Table 1: Age distribution of patients with traumatic TM perforationsAge in years Frequency (%)6 months-5 yrs 5 (7.9%)6 years-10 yrs 1 (1.6%)11-20 yrs 15 (23.5%)21-34 yrs 19 (29.7%)35-64 yrs 24 (37.7%)Table 2: Predisposition and sex of patientsPredisposition FrequencyMale FemaleSlap 15 8Instrumentation 4 3Self during ear cleaning 5 2RTI 9 1Foreign body 10 3Explosion 3Fall 1Total 46 18Page 2 of 4(page number not for citation purposes)BMC Research Notes 2009, 2:232 http://www.biomedcentral.com/1756-0500/2/232Traumatic tympanic membrane affects all age groups witha mean age of 29.2 yrs similar to a study from the south-eastern part of Nigeria that had a mean age of 27.6 yrs [13]with the highest incidence among the middle age groupsfrom our studies similar to some study [14] but differfrom other [13]. Male to female ratio was found to be2.5:1 with high predominance among males (72%). Thisis expected, as trauma is commoner in this group ofpatients similar to other series [5,13,14]. Both ears werealmost equally affected in the ratio of 1.0:1.3 right to left,this could be associated with the fact that most assailantswere right handed and likely that most of the acts oftrauma such as slap occurred with the assailant and vic-tims facing each other making the left ear to be predomi-nantly affected compared to the right side. Some of thecauses of overpressure include slap injuries and blast inju-ries. Slap injuries are extremely common and can be as aresult of either a hand or water slap and these injuries usu-ally result in a triangular or linear tear of the TM from pre-vious study [12]. These slap injuries could be a product offight, armed robbery attack as seen in our study howeverit was found to be commoner among the youths in morethan 50%of cases reviewed and those in the adult weredue to attack by the armed robbers or security agents. Thiswas the highest cause of traumatic tympanic membraneperforation in our study compared to a similar study inother region of Nigeria where fight with spouse was thecommonest aetiology recorded [13] which was the least inour study.Slap from fights was the commonest cause of the trau-matic perforation which was the commonest type of vio-lence seen between individuals, mostly between securityagents and the offender, then among students howeverother study found it resulting from marital conflictbetween wife and spouses [13] however the need to edu-cate the students and security agents on other punitivemeasure as there is predisposition to conductive hearingloss or an imminent chronic suppurative otitis media ifnot properly managed. Slap was commoner among malesthan the females similar to other study [13], then roadtraffic injury most of which resulted from temporal bonefracture with cerebrospinal fluid (CSF) leakage with lowfrequency (15.6%) in our environment from the data pre-sented, bleeding from the ear and damage to the ossicularattachment at the posterior-inferior part of the tympanicmembrane with resultant conductive hearing loss ofabout 7-20dB [12] however our own study did not evalu-ate the degree of hearing loss from these traumatic perfo-ration. The management protocol for skull base fracturewith TM perforation/CSF leakage is masterly inactivity toavoid contamination with an ascending infection.Attempt at removing foreign body, self ear cleaning withvariety of object cotton bud inclusive and wax removal inan unskilled manner either by the parents or the primarycare physician with TM perforation was an importantcause found mostly among the children similar to otherreports [5,6,10,11], thus the need for a primary care phy-sician to identify their limits with appropriate referral.Explosion is not a common phenomenon in our environ-ment as it is relatively a peaceful one. Fall from a heightwith bleeding from the ear was also observed in tenmonths old child which further assessment showed perfo-rated tympanic membrane.Traumatic perforations often occur in the healthy mem-bers of the community; and generally the prognosis isexcellent [6,8]. The two main factors that predispose tofailure of the perforation to heal are loss of tissue and sec-ondary infection. Secondary suppurative otitis mediaoccurred in 37.5% of the ears in this series. This resolvedwith both antibiotic impregnated topical wick ear dress-Table 3: Aetiological profile of TM perforations.Aetiology Frequency (%)Slaps 23 (35.9)Instrumentations 7 (10.9)Self Ear cleaning 7 (10.9)Road Traffic Injury 15 (23.5)Foreign body 8 (12.5)Explosions 3 (4.7)Falls 1 (1.6)Total 64 (100.0)Table 4: Sources of SlapsSources of slap Frequency (%)Security Agent 4 (17.4)Assault from Fight 7 (30.5)Spouse 2 (8.7)Armed Robbery 3 (13.0)Senior student/cultists 4 (17.4)Sibling 3 (13.0)Total 23 (100.0)Table 5: Clinical presentation of the patientsPresenting Symptoms Frequency (%)Hearing loss 61 (95.3)Bleeding 44 (68.8)CSF leak 10 (15.6)Dizziness 6 (9.4)Tinnitus 33 (52)Infection 24 (37.5)Pain 38 (59.4)Page 3 of 4(page number not for citation purposes)BMC Research Notes 2009, 2:232 http://www.biomedcentral.com/1756-0500/2/232Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentraling and systemic antibiotics with healing of the perfora-tions.The most effective management is masterly inactivity.Because of the risk of introducing infection, the ear shouldnot be cleaned out. The ear must be kept dry by preventingwater from entering the ear canal [6,8]. If the perforationfails to close spontaneously by 3-6 months (in the absenceof secondary infection), surgical closure is indicated [6,8].If the perforation fails to close spontaneously in 3-6months (in the absence of secondary infection), surgicalclosure is indicated [6,8]. However all our patient in thisstudy had conservative, non touch technique or non-sur-gical treatment. The follow up was observed to be an aver-age of thrice among the all the patients in the study.Healing with formation of neomembrane was observedonly in five patients (7.8%) and it is among the underfive's this is not surprising as they are still growing.In conclusion traumatic perforation of the tympanicmembrane is still common in our environment; affect allage groups, male more than the males, slap and RTI arethe commonest aetiologies seen, left ear affected morethan the right and sudden hearing loss is the commonestsymptom of presentation. Even though it is not a com-mon injury that is under-reported, there is the need toeducate the student and security agents on alternativepunitive measure, discourage the act of unskilled removalof foreign body, early identification, evaluation and refer-ral of patients by primary care physician who saw thesepatients to reduce the attendant morbidity.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsAOA perform the conception and design of the study, oracquisition of data, or analysis and interpretation of data,ASK assisted in drafting the article and proof reading themanuscript. SS assisted in drafting the article or revising itcritically for important intellectual content, ABS per-formed the final approval of the version to be submitted.All authors have read and approved the final manuscriptAcknowledgementsThe authors are grateful to the staff of the record department who assisted in retrieval of case file of patients.References1. 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Okafor BC: Otolaryngology in South Eastern Nigeria I: Pat-tern of Diseases of the Ear.  Nig Med J 1983, 13:11-19.8. Ijaduola GTA: The Principles of Management of Deafness.  NigMed Pract 1986, 12:19-25.9. Bhattia PL, Varughese R: Pattern of Otolaryngological Diseasesin Jos Community.  Nig Med J 1987, 17:67-73.10. Ladapo AA: Danger of foreign body in the ear.  Nig Med J 1979,9(1):120-122.11. Ijaduola GTA, Okeowo PA: Foreign body in the Ear and itsimportance: The Nigerian Experience.  J Trop Paed 1986,32:4-6.12. Schwaber Mitchell K: Trauma to the Middle Ear, Inner Ear, andTemporal Bone.  In Ballenger's Otorhinolaryngology Head and NeckSurgery Volume 14. Sixteenth edition. Edited by: James B Snow Jr, JohnJacob Ballenger. DC Becker Inc; 2003:345-356. 13. da Lilly-Tariah OB, Somefun AO: Traumatic perforation of thetympanic membrane in University of Port Harcourt Teach-ing Hospital, Port Harcourt.  Nigeria., Niger Postgrad Med J 2007,14(2):121-4.14. Gacek R R, Gacek M R: Anatomy of the Auditory and Vestibu-lar Systems.  In Ballenger's Otorhinolaryngology Head and Neck SurgeryVolume 1. Sixteenth edition. Edited by: James B Snow Jr, John JacobBallenger. DC Becker Inc, Ontario; 2003:1-5. Page 4 of 4(page number not for citation purposes)

Traumatic Tympanic Membrane perforation: An aetiological

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Traumatic Tympanic Membrane perforation: An aetiological profile

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