A 16 year-old male semi-professional swimmer has now presented twice with a left antero-superior tympanic membrane (TM) perforation following a URTI. The perforation is in the same location each time and is slightly larger than a pin hole. This causes him left aural pressure when underwater and a disconcerting squeaking sound in the ear when doing underwater tumble rolls. No otorrhea, tinnitus, hearing loss, vertigo. TM otherwise normal. The right TM is normal. Post-nasal space normal. Non-smoker. No ongoing history suggestive of chronic Eustachian tube (ET) dysfunction.
In the first occurrence, I advised water precautions (ear plug) and observation and it fully healed after 6 weeks. In this occurrence (6 months later) I have advised the same thing and will see him again in about 6 weeks to hopefully confirm healing.
This may be a case of bad luck and will never happen again. However, there is more likely an element of left-sided URTI-related ET dysfunction. Presuming this second perforation heals and perforation recurrence is likely in future, how best to prevent it in this swimmer within whom an intact TM is desirable? Balloon Eustachian tuboplasty? No imaging to date. I'm considering a CT temporal bones.
Make Tubomanometry (TMM) to Know the isobaric meaddle ear system status vis a vis his neurologic damage level, important to do or not tympanoplasty.
Tympanometry will be done once the TM has healed, yes. However, it might be the case that he only gets Eustachian tube dysfunction during URTI (the patient is symptomatically normal otherwise). If tympanometry is abnormal, it gives a strong case for BET. But what if he has tympanometry in between URTI and perforates again?
He has Eustachian tube dysfunction. Suggest a CT scan of his sinuses and clinical assessment of his nasal septum, possible allergic rhinitis or sinusitis
Hi Aaron,
I hope you are well.. Interesting case. It will be interesting to know if he is one of those who does a rather "strong" Valsalva when he feels his ear blocked (as someone with URTI would). Did he expand on how, when and what happens around the time he found out about the two perforations?
If you are thinking of investigating him, Do you think that a post-nasal space contrast-enhanced MRI might be more sensitive for ET dysfunction if you think of that as a factor?
Let me know how it goes.
I'm sure I will see you around
Check nasal status, probably topical steroids prescription.
Please consider not diving and using an ear plug.
Tympanogram to evaluate middle ear status
Hi Aaron,
Interesting case. The fact that he presents TM perforation after URTI strongly suggests that his Eustachian tube (ET) has suboptimal function that will only be evident when his ET is stressed such as URTI, nasal allergies, sinus, GERD or rapid changes in pressure (flight or dive). A few thoughts:
- Although you mentioned that he does not have ongoing hx of ET dysfunction (ETD), does he have a past hx of recurrent middle ear infections or fluids or any trouble equalizing middle ear pressure (MEP) when flying or diving?
- My understanding is that swimmers exhale forcefully through the nostrils during underwater tumble rolls to avoid water getting into the nasal cavity. Air getting into the middle ear and escaping through the perforation would explain the annoying squeaking sound when the perforation is present. That means two things: 1) his ET is not obstructed 2) as he does that all the time, his TMs are being constantly stretched and I wonder if they are hypercompliant or thinner in some areas, which can be seen in the tympanogram and otoscopy. That could explain why he is prone to TM perforations and, as said by another colleague, a simple Valsalva could cause a perforation.
- When you have obstructed type of ETD, TM perforation alleviates symptoms. Aural pressure in the presence of a perforation or after insertion of a ventilation tube actually suggests a patulous ET, a contra-indication for balloon dilation.
It is important to have in mind that the type of ETD (obstructed or patulous) can only be differentiated with ET function tests as also suggested by the colleagues, but they are not widely available. Tympanogram is probably going to be normal after his TM heals, so I would suggest:
- Ask him about what technique he uses during underwater tumble rolls, autophony (especially after exercises) and if he has the habit of constantly sniff or do Valsalva
- If next time you see him his TM perforation has healed:
1) During otomicroscopy or oto-video-endoscopy (sitting position) observe:
A) if there is movement of the TM concurrent with breathing from the ipsilateral nostril. Breath from soft to forceful while blocking the contralateral nostril.
B) if his TM is blown out during Valsalva and if the middle ear keeps the positive pressure (I would be careful and ask for a very gentle Valsalva if TM is too thin or recently healed). Patulous people do not hold positive or negative MEP;
2) Tympanogram: do a sequence of 3 tympanograms and make notes of the MEP 1) at baseline, 2) after a gentle Valsalva and 3) after a swallow. Type of changes in MEP is useful to assess dynamic ET function.
- If next time you see him his TM has not healed yet:
1) Excellent opportunity to do an Inflation-deflation test (this is built-in in most tympanometers).
Sorry for the long comments - just love this stuff!
All the best and keep us posted!
Miriam
Thank you everyone for your valuable suggestions and insights. Miriam S. Teixeira thank you especially for an extremely well-thought out approach to this patient. I shall certainly try your suggestions and report back.
If it reperforates then I would suggest a cartilage tympanoplasty
Ayurved.
Ayurved can provide few option inthis regard. As recurrent urti is one of the cause, Nashya for 7 days for 2 to 3 sittings ( medicated oil as nasal drop) and Ear wick with medicated oil can prevent and heal the TMP. and reoccurence.
Thank you for this case does the patient have septal deviation to the left side or straight septum
Hello All, I have reviewed this patient. Miriam S. Teixeira he does exhale during his tumble rolls but denies autophony even post-exercise. He also denies a sniffing or Valsalva habit. The antero-superior portion of his TM (the part that perforates) is thinned, but there is no movement during quiet respiration, even when his contralateral nostril is blocked. His septum is straight.
Based on this, I have suggested a strengthening of the TM via cartilage tympanoplasty, as mentioned by you Bruce Black - what is the general consensus on this?
Hi Aaron,
It is tempting to fix the end product of the process that is leading to the perforation (cartilage tympanoplasty in this case) which is a totally sensible procedure to do.
However, It is worth, especially if the TM has healed already, to try two things first: IgA levels, pneumococcal antibody titers and for the patient to have his flu vaccine if he does not have it already.
There is a chance that he might still need something done if the thin area is large enough with risk of future retraction.
an interesting and useful information here. thanks to all of you.
Probably ETF is not a factor here, as all facts given by Dr Aaron suggests.
Still, it may be prudent to do ETF testing before diving as suggested by Miriam.
'2) Tympanogram: do a sequence of 3 tympanograms and make notes of the MEP 1) at baseline, 2) after a gentle Valsalva and 3) after a swallow. Type of changes in MEP is useful to assess dynamic ET function."
though practical considerations are important here. We did regularly carried out ETF testing for aspirants of diving in sea. But they were holiday visitors and hence easy to monitor during the short stay.....
Hope the young man do well after cartilage tympanoplasty.