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©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

Kristi McGowin, MSN, CPNP

Children’s Mercy Hospital

Kansas City, MO

Is that a Hole? Evaluation and Is that a Hole? Evaluation and Treatment of TM PerforationsTreatment of TM Perforations


Disclosure:Disclosure:

No conflicts of interest were identified by the planning committee, faculty, authors and reviewers for this program.


OutlineOutline

• Identify Ear Anatomy

• Discuss causes of tympanic membrane

perforations

• Discuss management of perforations

• Discuss hearing evaluation

• Discuss TM perf repairs


Ear AnatomyEar Anatomy

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©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/137 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

Causes of Perforations


• Acute Otitis Media


• Trauma


• Foreign body


• Tube placement

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TM PerforationsTM Perforations


Management of PerforationsManagement of Perforations

• Monitor size and location of perf

• Evaluate margins of perf

– cholesteatoma

• Follow audiogram

• Stress water precautions


CholesteatomaCholesteatoma� Squamous epithelium (skin) in

middle ear or mastoid

� Congenital and Acquired

� Primary acquired

� Secondary acquired

� Conductive Hearing Loss and

Otorrhea

� Treatment:

� Tympanoplasty +/-

Mastoidectomy

� (Second Stage)

Ossiculoplasty



Follow audiogramFollow audiogram

Normal Hearing 0-25 dB

Mild (Hearing Loss) 26-40 dB

Moderate 41-55 dB

Moderately Severe 56-70 dB

Severe 71-90 dB

Profound > 90 dB


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Water PrecautionsWater Precautions

• KEEP EAR DRY


PerfPerf RepairsRepairs

• Paper Patch Myringoplasty

– Can be done in clinic on some patients

– Usually OR procedure (especially in kids)

– Keep ear dry for 4 weeks post op

– Follow up in 4-6 weeks to evaluate closure


PerfPerf RepairsRepairs

• Fat Graft Myringoplasty


TympanoplastyTympanoplasty

• Reconstruction of the eardrum and/or the

small bones (ossicles) of the middle ear.

• A graft is used to repair or replace the ear

drum.

• Can also be to explore the middle ear

space


TympanoplastyTympanoplasty• Graft can be fat, cartilage or fascia

• Fascia is most common

• Graft is harvested from another area,

behind the ear or thigh (typically).

• Packing is used in the middle ear and

external ear canal to keep graft in place.

• Can be done with or without

mastoidectomy©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

Cartilage

Tympanoplasty

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Fascia Fascia TympanoplastyTympanoplasty



• Transcanal approach

– No incision

• Postauricular approach

– Post auricular incision

• Medial/underlay

• Lateral/overlay


Tympanoplasty: Medial

Graft (Underlay)


Tympanoplasty and

Mastoidectomy


Tympanoplasty and

Mastoidectomy



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Case StudyCase Study

• 9 year old female with history of traumatic

perforation of the left ear a year ago.

Exam reveals a large central perf.

Audiogram notes a moderate left

conductive hearing loss.

• What else do we need to know?

• What is our plan?


Case StudyCase Study

• 6 year old female with history of bilateral

myringotomy at 2 years of age. Right TM

with small central perf. Audiogram is

normal.

• What else do we need to know?

• What is our plan?


Children’s Mercy Kansas CityChildren’s Mercy Kansas City


Children’s Mercy ENTChildren’s Mercy ENT


Together We’re Together We’re Working WondersWorking Wonders

www.childrensmercy.org


QUESTIONS???

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Contact InformationContact Information

• Kristi McGowin, MSN, CPNP

• [email protected]

• Office: 816-234-6297


ReferencesReferences

• Bluestone, C., Stool, S., Alper, C., Arjamand, E., Casselbrant, M., Dohar, J., Yellon,R.

(2005). Pediatric Otolaryngology, 4th Edition. Saunders: Philadelphia.

• Bluestone, C., Stool, S. (2004). Atlas of Pediatric Otolaryngology. Saunders:

Philadelphia.

• Sanna, M., Russo, A., De Donato, G., Caruso, A., & Taibah, A. (2002). Color Atlas of

Otoscopy. Thieme Verlag: Germany.

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