Determinants of spontaneous healing in traumatic
ORIGINAL ARTICLE
perforations of the tympanic membrane
Orji, F.T. & Agu, C.C.
Department of Otolaryngology, Federal Medical Center Umuahia, Abia State, Nigeria
Accepted for publication 30 May 2008
Clin. Otolaryngol. 2008, 33, 420–426
Objectives: To analyse the various factors influencing
spontaneous healing of traumatic tympanic membrane
perforation in West Africa.
Study design: Prospective clinical study.
Setting: Tertiary referral centre.
Participants: Consecutive patients with traumatic tym-
panic membrane perforations without history of previous
middle ear disease.
Main outcome measures: Healing outcome at 4, 8,
12 weeks; effects of perforation size, location, and mode
of injury, active intervention and ear discharge on healing
outcome.
Results: Fifty-three patients, 32 (60%) men and 21 (40%)
women, aged 2–86 years, with traumatic tympanic mem-
brane perforation who met our inclusion criteria were
analysed. Ninety-four percent of the perforations healed
spontaneously. Spontaneous healing was significantly
correlated with age (P < 0.05). It was significantly delayed
by large perforations estimated at 50% or more of entire
tympanic membrane, ear discharge, wrong intervention on
acute perforation by ear syringing, and by penetrating inju-
ries sustained through the ear canal (P < 0.05, P < 0.01,
Tympanic membrane (TM) serves as a key component of
the tympano-ossicular system for sound transmission.
TM perforation is commonly encountered in otologic
practice and can result from various causes such as
trauma, infections of the middle ear and malignant
tumours of the ear.1 Traumatic causes may result from
assault, self-inflicted injuries, fights, iatrogenic injuries,
explosive blast injuries2 and non-explosive blast inju-
ries.3,4 The later refers to otologic trauma, where a blow
to the ear seals the external meatus, and causes a sudden
Correspondence: Foster T. Orji, FWACS, FMCORL, Department of
Otolaryngology, University of Nigeria Teaching Hospital, Ituku-Ozalla,
Enugu State, Nigeria. Tel.: +234 80 3677 3342; e-mail: tochiorji@
yahoo.com
420 Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
P < 0.01 and P < 0.01 respectively). Perforations in the
anterior versus posterior quadrants showed no significant
difference in the healing rate (P > 0.05). Non-healing of
the traumatic perforation was significantly associated with
the large perforations, ear discharge and wrong interven-
tion by ear syringing in chi-square test (P = 0.01, P = 0.02
and P < 0.001 respectively), but only with penetrating inju-
ries sustained through the ear canal and the ear syringing
intervention in logistic regression test (P = 0.02 and
P = 0.04 respectively).
Conclusion: The rate of spontaneous healing of traumatic
tympanic membrane perforation varied inversely with age
of patient and size of perforation. It was delayed by
middle-ear infection, as well as in ears that sustain direct
injuries and in ears that had wrong interventions.
However, it was not dependent on whether the perfora-
tion was in the anterior or posterior location. Logistic
regression analysis revealed that penetrating injuries
sustained through the ear canal and the ear syringing
intervention were the only risk factors important in pre-
dicting the non-healing of traumatic tympanic
membrane perforation.
increase of air pressure that strikes the TM. In the West
African sub-region, the community health attendants and
the primary care physicians are usually the first to see
these patients and intervene in the treatment, often
resulting in complications and poor healing outcome.1,5
Although high rates of spontaneous healing following
conservative management of traumatic TM perforation
are reported in many studies,2–5 there have been few sys-
tematic studies of the factors determining the outcome of
the spontaneous healing of traumatic TM perforations.
The purpose of the present study was to evaluate the var-
ious factors influencing the healing outcome of traumatic
TM perforation. The results obtained could assist the
community health workers and primary care physicians
in making informed management decisions.
 2008 The Authors
 Determinants of healing in traumatic tympanic membrane perforation
Methods
Study design
This is a prospective study conducted during 20-month
period ending November 10, 2007 in the Ear, Nose, and
Throat clinic of the Federal Medical Center Umuahia-
Nigeria.
Ethical consideration
The research protocol was reviewed and approved by the
Institutional Ethical Review Board. Informed consent was
obtained from each eligible subject before enrolment into
the study.
Patient recruitment and data collection
Fifty-eight consecutive patients who suffered injuries or
blow to the ear resulting in acute TM perforations were
recruited. Subjects who were included presented within
14 days of the injuries, and had no history of previous
middle ear disease. Two patients were excluded on
account of previous history of bilateral otorrhoea.
At the initial assessment, a structured interview was con-
ducted for each patient and the following information were
recorded: age, gender of patients, side of injury, cause of
injury, associated symptoms and nature of intervention
prior to presentation. Each patient underwent a thorough
ear and general physical examinations including Rinne and
Weber tuning fork tests. The location and size of the TM
perforations were sketched by hand. The location of TM
perforation was determined to be anterior, or posterior or
both anterior and posterior with respect to an imaginary
vertical line through the manubrium. The size of the perfo-
ration was expressed as an estimated percentage of the
entire TM. Standard pure-tone audiometric testing was
performed. Pure-tone averages were determined for air and
bone conductions at 500, 1000, 2000 and 4000 Hz.
A conservative management approach was adopted
and follow-up visits were scheduled at 2, 4, 8, and
12 weeks so as to have a uniform baseline assessment at
2 weeks before significant healing would have taken place,
and to evaluate the rate of healing at a regular 4-weekly
interval. During the follow-up visits, the eardrums were
re-examined. Pure tone audiometric tests were repeated
following healing of the perforation.
Analysis of data
Data were analysed with the aid of the Statistical Pack-
age for Social Sciences (SPSS), version 11.5. Univariate
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Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
421
associations between the potential explanatory factors and
healing rate ⁄ non-healing of TM perforation were tested
with chi-square and Pearson correlation tests. A multivar-
iate analysis of the same factors was assessed with logistic
regression test. Data were presented in simple descriptive
form, tables and chart.
Results
All the 58 patients demonstrated acute central perfora-
tions of the TM that were confined solely to the pars
tensa. Nine percent of the 58 patients were lost to follow-
up. Data from 53 patients who met our inclusion criteria
were analysed. They were 32 (60%) men and 21 (40%)
women. Their ages ranged from 2 to 86 years. There was
significant correlation between age and the rate of sponta-
neous healing of the TM perforations (r = 0.30;
P < 0.05). The younger patients healed significantly ear-
lier than the older ones. The relationship between age
and duration of healing was portrayed in Table 3.
The patients were divided into four subgroups depend-
ing on the healing outcome during the re-evaluation at
the 2nd, 4th, 8th and 12th week of their injuries: (i) heal-
ing by the 4th week, (ii) healing by the 8th week, (iii)
healing by the 12th week and (iv) non-healing by the
12th week. None of the TM perforations healed at the
2nd week evaluation. The healing outcome was regarded
as satisfactory if complete healing was achieved within
8 weeks of injury. Beyond the 8th week, the healing out-
come was regarded as either delayed (perforations that
were able to achieve complete healing by the 12th week)
or poor (non-healing by the 12th week).
As shown in Table 1, 94% of the perforations achieved
spontaneous healing within 12 weeks. However, satisfac-
tory healing was observed in 81% of the perforations.
Three patients (6%) did not show significant healing
by the 12th week despite achieving dryness of the ears
for minimum of 4 weeks. They are now considered for
surgical repair.
Table 1. Healing outcome during follow-up re-evaluation
(n = 53)
Spontaneous Number of
healing patients Percentage of total (%)
2nd week 0 0
4th week 32 60
8th week 11 21
12th week 7 13
Non-healing 3 6
Total 53 100
422 F.T. Orji & C.C. Agu

Table 2. Hearing outcomes following traumatic perforation of TM and following subsequent healing

Percentage
Air–bone gap (dB)
0.5, 1, 2, 4 kHz Mean SD <0 0–10 11–20 21–30 >30

Pre-healing 20 11 0 20 31 30 19
Post-healing 6 5 0 81 15 4 0
Percentage change

dB Better dB Worse

CHANGE (negative values indicate better hearing) Mean SD £)20 )19 to )10 )9 to 0 1–10 >10
Bone conduction (dB) 0.5, 1, 2, 4 kHz )1.7 11.9 1 2 84 13 0
Air conduction (dB) 0.5, 1, 2, 4 kHz )16.2 18.4 24 51 20 4 1

Table 2 shows the hearing outcomes as at presentation 40 Spontaneous healing

and following healing of the TM perforations. The mean 4th week
air–bone gap at presentation was 20 ± 11 dB, and was
8th week
6 ± 5 dB following healing. The difference was significant 71%
30 12th week
(t = 14.53; P < 0.01).
Non-healing
Number of patients
Effect of size and location of TM perforation on the
rate of spontaneous healing 20

The size of the perforation was expressed as a percentage

estimate of the entire TM which was recorded as 10%,
25%, 50% and 75%. These were grouped into two: (i)
small perforation – perforations estimated at less than
50% of the entire TM and (ii) large perforation – perfo-
rations estimated at 50% or more of the entire TM. The
relationship between the size of perforation and the rate
of spontaneous healing is as shown in Fig. 1 and Table 3.
Small-sized perforations were observed in 83% of the
patients, and large perforations were recorded in 17% of
the patients. Eighty-six percent of the small-sized perfora-
tions and 56% of large perforations healed completely
within 8th week of the injuries. Large perforations were
significantly associated with delayed and poor healing
(v2 = 4.63; P < 0.05).
Ears were also divided into three subgroups on the
basis of the location of the perforation with respect to an
imaginary vertical line through the manubrium: anterior
perforations, n = 15, posterior perforations, n = 16, com-
bined anterior and posterior perforations, n = 22. This
was shown in Table 3. No significant difference was
found in the rate of the spontaneous healing between the
anterior and posterior perforations (v2 = 5.13; P > 0.05).
Effect of intervention, mode of injury and ear
discharge on spontaneous healing
Table 4 displays the rate of spontaneous healing of the
perforation on the basis of whether there was interference
Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
10
16%
11%
45%
22% 22%
11% 2%
0
Large Small
Size of perforation
Fig. 1. Spontaneous healing outcome at the follow-up
re-evaluation for large versus small sized perforations. The first
three columns indicate the number of perforated TM that healed
at 4th, 8th and 12th week of injury respectively. The last column
indicates the non-healed perforation by 12th week of injury.
with the ears or not prior to presentation. Ninety-four
percent of perforations that were not interfered with
healed spontaneously within 4 weeks of the injuries.
Eighty-five percent of the 20 TM perforations that were
interfered with healed spontaneously, but beyond 4 weeks
of the injuries. It was pertinent to note that the three ears
that did not achieve significant healing of their perfora-
tions were all irrigated with water following the injuries.
Active intervention on the acute TM perforation was sig-
nificantly associated with delayed and poor healing
(v2 = 9.37; P < 0.01). However, analysis of the various
modes of intervention showed that only irrigation with
water was significantly associated with non-healing of TM
perforation (P < 0.001), as shown in Table 6.
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 Determinants of healing in traumatic tympanic membrane perforation 423

Table 3. The distribution of the

duration of spontaneous healing of TM Spontaneous healing duration
perforation in relation to the age of Variables 4 weeks 8 weeks 12 weeks Non-healing Total
patients, size, and site of perforation
(n = 53) Age (years)
0–20 4 (61%) (26%) 3 (13%) 0 (0%) 23 (100%)
21–40 17 (68%) 4 (16%) 2 (8%) 2 (8%) 25 (100%)
>40 1 (20%) 1 (20%) 2 (40%) 1 (20%) 5 (100%)
Size of perforation (percentage estimate of TM)
Small (<50%) 31 (71%) 7 (16%) 5 (11%) 1 (2%) 44 (100%)
Large (‡25%) 1 (11%) 4 (45%) 2 (22%) 2 (22%) 9 (100%)
Site of perforation
Anterior 13 (87%) 0 (0%) 2 (13%) 0 (0%) 15 (100%)
Posterior 12 (75%) 4 (25%) 0 (0%) 0 (0%) 16 (100%)
Antero-posterior 7 (32%) 7 (32%) 5 (23%) 3 (14%) 22 (100%)

Table 4. Mode of intervention versus

spontaneous healing outcome (n = 53) Number of healed and non-healed perforations
Healing at Healing at Healing Non-healing
Previous intervention 4 weeks 8 weeks at 12 weeks by 12 weeks Total

No intervention 29 2 2 0 33
Irrigation with water 0 1 2 3 6
Irrigation with hydrogen 1 3 1 0 5
peroxide
Use of ear drops 2 5 2 0 9
Total 32 11 7 3 53

Table 5. Distribution of the duration

of spontaneous healing of TM perforation Spontaneous healing duration
in relation to the mechanism of injury Cause of injury 4 weeks 8 weeks 12 weeks Non-healing Total
(n = 53)
Slap 24 8 1 1 34
Cotton bud injury 3 2 0 0 5
Iatrogenic injury 4 1 4 2 11
Stab during fight 0 0 2 0 2
Den gun explosion 1 0 0 0 1
Summary of cause of injury
Blast injury 25 (71%) 8 (23%) 1 (3%) 1 (3%) 35 (100%)
Penetrating injury 7 (39%) 3 (17%) 6 (33%) 2 (11%) 18 (100%)
Total 32 11 7 3 53

Table 5 shows the distribution of the healing outcome
in relation to the mode of the injuries. The mode of the
injury was categorized into ‘penetrating injury’ through
the ear canal and ‘blast injury’. Iatrogenic TM perfora-
tions arising from attempted foreign body removal by
primary care physicians and community health workers
constituted 61% of the penetrating injuries. Sixty percent
of the patients in the delayed and poor healing groups
 2008 The Authors
Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
were observed in perforations that resulted from iatro-
genic injuries. Delayed and poor healing rates were signif-
icantly associated with TM perforations resulting from
penetrating injuries (v2 = 6.34; P < 0.01).
History of purulent ear discharge was recorded in 38%
(20) of the perforations at presentation as shown in
Fig. 2. Moreover, 90% of the patients that gave a history
of active interference presented with ear discharge.
424 F.T. Orji & C.C. Agu

40 Spontaneous healing traumatic TM perforation on chi square and logistic

4th week
regression analysis tests. Strong significant connections
were found between non-healing and intervention by ear
8th week
irrigation with water, large perforation and ear discharge
12th week in the chi-square test (P < 0.001; risk estimate = 17,
30 88%
Non-healing P < 0.01; risk estimate = 12 and P < 0.02; risk esti-
mate = 3 respectively).
Number of patients

In the analysis of logistic regression, direct injury

through the ear canal and intervention by ear irrigation
20 with water were distinctly related to non-healing of TM
perforation (P = 0.02 and P = 0.04 respectively) with rel-
ative risks of 21 and 11 respectively.

10 45%
25%
15%
6% 6%
0 ing from 80% to 94% were reported by various research-
Absent Present
Ear discharge
Fig. 2. Effect of ear discharge on rate of spontaneous healing.
The patients were grouped into two: those who presented with
ear discharge and those without. The rate of healing for each
group is indicated by the number of perforations who healed at
4, 8, and 12 weeks following the injuries.
Similarly, in 61% of perforations resulting from penetrat-
ing injuries through the ear canals, there was associated
history of ear discharge. The presence of ear discharge
following traumatic TM perforation was significantly
associated with delayed and poor spontaneous healing
(v2 = 9.37; P < 0.01).
Relationship of different factors with non-healing of
TM perforation: univariate and multivariate analysis
Table 6 shows the analysis of the association and risk esti-
mates of different factors in relation to non-healing of
Discussion
Trauma was ranked as the second most common cause of
TM perforation in the West African sub-region.1,5 Trau-
15% matic perforation of the TM has been the subject of a
large number of studies. Spontaneous healing rates rang-
ers.3,4,6,8 In view of the excellent spontaneous healing
outcome of TM perforation resulting from trauma, con-
servative management is often generally adopted.2–8 How-
ever, some cases of acute TM perforations had been
inappropriately managed by general practitioners and
family physicians, causing delay in referrals to the otolar-
yngologists. Such late referrals were reported to have led
to the development of chronic TM perforation.1,9 Because
of the risk of introducing infection, during the first
2 weeks after traumatic perforation, it has been advocated
that inspection only should be done, and instrumenta-
tion, cleaning and other active intervention avoided
unless contaminating material is found in the meatus or
there is evidence of active infection.10,11 Antibiotic ear
drops, in the absence of infection, were believed to be of
no value and may well assist invasion by opportunistic
organisms.10 Early surgical repair is not usually indicated,
as healing of traumatic TM perforation is mostly without
complication.2–8 Appropriate surgical repair is often

Table 6. Analysis of the association and

Logistic regression risk estimates of different factors in
Chi-square test analysis relation to non-healing of traumatic TM
Variable v2 P-value Odds ratio P-value Odds ratio perforation on chi square and logistic
regression analysis tests
Presence of ear discharge 5.5 0.02 2.9 0.96 1.1
Penetrating injury 1.5 0.22 4.3 0.02 21.3
Large perforation 5.6 0.01 12.3 0.51 0.3
Intervention by ear syringing 24.9 <0.001 16.7 0.04 11.1
Hydrogen peroxide ear rinsing 0.3 0.50 1.1 0.95 0.8
Intervention by the use ear drops 0.6 0.40 1.2 0.32 0.1
Age (>40 years) 0.3 0.58 2.0 0.90 1.0

 2008 The Authors

Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
 Determinants of healing in traumatic tympanic membrane perforation
indicated for traumatic TM perforation persisting 3–
6 months after the injury.7,8,11,12
In this study, spontaneous healing of the TM perfora-
tion with conservative management was observed in 94%
of the patients. Healing of the perforation was always asso-
ciated with significant closure of the air–bone gap. This is
in agreement with other reports from other researchers,
even though they studied TM perforation resulting from
only non-explosive blast injuries in their series.3,4 Sponta-
neous healing rate of 78.7% was reported in a study that
reviewed several literatures on the traumatically perforated
TM.6 However, the durations of the follow up were not
stated. It is conceivable that the shorter the duration of fol-
low up, the more likely the rate of spontaneous healing in
a given series would be low. The results of our study por-
trayed some factors that significantly influenced the rate
and outcome of spontaneous healing of the TM perfora-
tions, which we considered in more detail.
Factors related to the rate of spontaneous healing
of TM perforation in univariate analysis
Age
We found that the healing was fastest in the youngest age
group and slowed as age increased. However, the effect of
age on non-healing of TM perforation was not signifi-
cant. The rate of wound healing was reported to be faster
in the young individuals, but however, normal in the old
people.13,14 The higher protein turn over in the young
individuals is believed to account for their faster healing
rate.13 The nutritional conditions and social status of the
patients were however not considered in this study.
Size and location of perforation
We observed that larger perforations resulted in signifi-
cant delay in the spontaneous healing as well as non-
healing of the perforations. This agrees with reports from
other researchers.6,15,16 In an experimental study on the
spontaneous healing of induced TM perforations in the
rats, it was concluded that TM perforation healed by
means of epithelial migration arising from the annulus
and the handle of malleus spreading across the edges of
the perforations to cover tissue defect.17 It is conceivable
that the larger the perforations, the longer it will take the
epithelial migration to cover the wider tissue defects.
All the perforations in this study were central, no
marginal or attic perforation was observed. This is in
agreement with other reports.1–8 The rate of spontaneous
healing was not significantly influenced by the location
of the TM perforations. Regardless of whether the
 2008 The Authors
Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
425
perforation was anterior, or posterior, the rates of healing
were significantly the same. This agrees with published
experimental work in rats which showed that the healing
of induced TM perforation in rat is independent of the
location provided it is not marginal or attic perforation.17
Intervention, mode of injury and presence of ear
discharge
Our results showed that interference with the ears by the
general practitioners and community health workers by
irrigating the ears with water following the injuries
resulted in significant delay in the healing process as well
as non-healing of the perforation. In 50% of the ears that
were irrigated with water, there was no significant healing
after 12 weeks of their injuries. Even though the observed
delays in the rate of healing among the patients who used
antibiotic-based ear drops or had their ears rinsed with
hydrogen peroxide following injuries were not significant,
only 22% and 20% of them healed within 4 weeks
respectively, compared with 88% of perforations in the
non-intervention group that healed within 4 weeks.
These modes of interventions most probably drove-in
contaminants in the ear canal into the middle ear
through the rent in the TM and resulted in middle ear
infections. Antibiotic-based ear drops may well assist
invasion by opportunistic organisms.10 We observed that
90% of these patients who had these wrong interventions
also had middle ear infection evidenced by purulent ear
discharge. The presence of infection in an injured tissue
or organ has long been recognized as a major factor
impairing proper wound healing by causing continued
inflammation and further tissue damage.10,13 Such infec-
tion in the presence of TM perforation has resulted in
poor healing outcome requiring appropriate referral for
surgical repair.1,9,18 It is therefore reasonable to avoid any
form of interference with the injured ear in the early
phase of the management of traumatic TM perforation
except when infection has ensued. In such case, the use
of appropriate systemic and topical antibiotic ear drops is
justifiable. The act of irrigating the ear with water in the
presence of TM perforation should be condemned in its
entirety. The accumulated debris or pus can be safely
cleared by dry-mopping or gentle suction.
Our results also showed that the rate of healing was
significantly influenced by the mode of injury. It was sig-
nificantly delayed in perforations resulting from direct
injuries through the ear canal. It is conceivable that mid-
dle ear infection is more likely to occur in perforation
resulting from direct injuries through the ear canal than
in perforation resulting from non-explosive blast
injuries.18 This fact is supported by the observation of ear
426 F.T. Orji & C.C. Agu
discharge in significant proportion of the patients with
TM perforations resulting from direct injuries in our
present study.
In view of the higher risk of developing middle ear
infection in perforations resulting from penetrating inju-
ries, such cases should be referred early to the otolaryn-
gologist for a better management outcome.
Factors related to non-healing of TM perforation on
multivariate analysis
Penetrating injury through the ear canal was highly asso-
ciated with non-healing of TM perforation. It was identi-
fiably the most important factor in predicting the
traumatic perforations that would not heal spontaneously.
The relative risk of non-healing is 21 times as high
among patients with penetrating injuries as among those
with blast injuries. Intervention by ear irrigation with
water was also strongly associated with non-healing with
a relative risk of 11. Although large perforations and ear
discharge were associated with non-healing in chi-square
test, their effects were not significant in logistic regression
test. It is possible that the connection between large per-
foration and ear discharge on the one hand and non-
healing of perforation on the other hand is evident
among patients with penetrating injuries and ⁄ or among
those who had their ears irrigated with water.
Conclusion
The rate of spontaneous healing of the perforation was
fastest in the youngest patients and varied inversely with
size of perforation. Penetrating injuries through the ear
canals, as well as wrong interventions on acute TM perfo-
rations predisposed to development of middle ear infec-
tion, which in turn led to significant delay in the healing.
However, the rate of healing was not significantly influ-
enced by the location of the perforations.
Non-healing of traumatic TM perforation was associ-
ated with ear discharge, wrong interventions by ear
syringing, and large perforations estimated at 50% of
entire TM in the chi-square test but only with direct inju-
ries through the ear canals and wrong interventions by
ear syringing in the logistic regression test. The most
important risk factor for the non-healing of traumatic
TM perforation was direct injury sustained through the
ear canal.
Conflict of interest
None to declare.
Journal compilation  2008 Blackwell Publishing Ltd • Clinical Otolaryngology 33, 420–426
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