Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments | Emergency Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Pannu  KK, Chadha  S, Kumar  D, Preeti.  Evaluation of hearing loss in tympanic membrane perforation.  Indian J Otolaryngol Head Neck Surg. 2011;63(3):208-213.PubMedGoogle ScholarCrossref
Voss  SE, Rosowski  JJ, Merchant  SN, Peake  WT.  Middle-ear function with tympanic-membrane perforations, I: measurements and mechanisms.  J Acoust Soc Am. 2001;110(3, pt 1):1432-1444.PubMedGoogle ScholarCrossref
Mehta  RP, Rosowski  JJ, Voss  SE, O’Neil  E, Merchant  SN.  Determinants of hearing loss in perforations of the tympanic membrane.  Otol Neurotol. 2006;27(2):136-143. PubMedGoogle ScholarCrossref
Kozin  ED, Sethi  RK, Remenschneider  AK,  et al.  Epidemiology of otologic diagnoses in United States emergency departments.  Laryngoscope. 2015;125(8):1926-1933.PubMedGoogle ScholarCrossref
Ibekwe  TS, Ijaduola  GT, Nwaorgu  OG.  Tympanic membrane perforation among adults in West Africa.  Otol Neurotol. 2007;28(3):348-352. PubMedGoogle ScholarCrossref
Smith  M, Darrat  I, Seidman  M.  Otologic complications of cotton swab use: one institution’s experience.  Laryngoscope. 2012;122(2):409-411.PubMedGoogle ScholarCrossref
The “Q” stands for quality! Accessed September 1, 2016.
Robertson  MS.  The misuse of cotton wool buds.  N Z Med J. 1972;75(476):37.PubMedGoogle Scholar
Barton  RT.  Q-tip otalgia.  JAMA. 1972;220(12):1619.PubMedGoogle ScholarCrossref
Wohlgelernter  J, Gross  M, Eliashar  R.  Traumatic perforation of tympanic membrane by cotton tipped applicator.  J Trauma. 2007;62(4):1061.PubMedGoogle ScholarCrossref
Hobson  JC, Lavy  JA.  Use and abuse of cotton buds.  J R Soc Med. 2005;98(8):360-361.PubMedGoogle ScholarCrossref
Pulec  JL, Deguine  C.  Traumatic perforation: Q-tip injury.  Ear Nose Throat J. 2003;82(7):484.PubMedGoogle Scholar
Afolabi  OA, Aremu  SK, Alabi  BS, Segun-Busari  S.  Traumatic tympanic membrane perforation: an aetiological profile.  BMC Res Notes. 2009;2:232.PubMedGoogle ScholarCrossref
Kraus  F, Hagen  R.  The traumatic tympanic membrane perforation—aetiology and therapy  [in German].  Laryngorhinootologie. 2015;94(9):596-600.PubMedGoogle ScholarCrossref
Lawrence  LA, Svider  PF, Raza  SN, Zuliani  G, Carron  MA, Folbe  AJ.  Hockey-related facial injuries: a population-based analysis.  Laryngoscope. 2015;125(3):589-593. PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Injuries from batteries among children aged <13 years—United States, 1995-2010.  MMWR Morb Mortal Wkly Rep. 2012;61(34):661-666.PubMedGoogle Scholar
Carniol  ET, Shaigany  K, Svider  PF,  et al.  “Beaned”: a 5-year analysis of baseball-related injuries of the face.  Otolaryngol Head Neck Surg. 2015;153(6):957-961.PubMedGoogle ScholarCrossref
US Consumer Product Safety Commission. NEISS Coding Manual. Published January 2017. Accessed October 30, 2017.
Lou  ZC, Tang  YM, Yang  J.  A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation.  Clin Otolaryngol. 2011;36(5):450-460.PubMedGoogle ScholarCrossref
Jellinge  ME, Kristensen  S, Larsen  K.  Spontaneous closure of traumatic tympanic membrane perforations: observational study.  J Laryngol Otol. 2015;129(10):950-954.PubMedGoogle ScholarCrossref
Original Investigation
February 2018

Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
  • 3Department of Otolaryngology–Head and Neck Surgery, University of Maryland, Baltimore
  • 4Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
  • 5Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
  • 6Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark
  • 7Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark
JAMA Otolaryngol Head Neck Surg. 2018;144(2):136-139. doi:10.1001/jamaoto.2017.2550
Key Points

Question  What are the leading causes of traumatic tympanic membrane perforation in the United States?

Findings  In this cross-sectional analysis of 949 emergency department visits, foreign body instrumentation (including cotton-tipped applicators) was the most frequent cause of traumatic tympanic membrane perforations.

Meaning  The leading cause of traumatic tympanic membrane perforations may be preventable, and patient education may prevent this frequent cause of injury.


Importance  Tympanic membrane perforations (TMPs) are frequent events leading to evaluation in the primary care and otolaryngology offices or the emergency department (ED). Despite specific warning labels on packaging of cotton-tipped applicators regarding the risk of injury to the ear canal with personal use, these products are commonly used to remove ear cerumen.

Objective  To analyze the mechanism of injury for traumatic TMPs among patients presenting to the ED.

Design, Setting, and Participants  Cross-sectional analysis of cases from 100 emergency departments in the United States. The National Electronic Injury Surveillance System was searched on April 3, 2015, for ear-related injuries with analysis information regarding patient age, patient sex, time and date of injury, specific injury diagnoses, and specific injury mechanisms that occurred across 5 years, from January 1, 2010, through December 31, 2014.

Main Outcomes and Measures  Diagnoses of traumatic TMP documented in the ED visit record as well as patient demographics, diagnoses, and other aspects of the injury, including mechanism of injury.

Results  There were 949 case entries in the database for traumatic TMP, which extrapolates to 4852 ED visits nationally. Of 949 patients evaluated, 568 (59.8%) were men and 381 (40.2%) were women resulting in a male to female ratio of 1.49:1. Most injuries occurred in patients 18 years or younger (602 of 949 [63.4%]) with children younger than 6 years most at risk (331 of 949 [34.9%]). Ear canal instrumentation including foreign bodies was noted in 581 of 949 cases (61.2%), with cotton-tipped applicators noted in 261 (44.9%) of these cases. While foreign body instrumentation represented the leading cause of traumatic TMP in patients aged 0 to 5 years (284 of 331 cases [85.8%]), 6 to 12 years (108 of 158 [68.4%]), 19 to 36 years (85 of 223 [38.1%]), 37 to 54 years (48 of 91 [52.7%]), and 55 years or older (22 of 33 [66.7%]), water trauma was the leading cause of TMP in patients aged 13 to 18 years (43 of 113 cases [38.1%]).

Conclusions and Relevance  Traumatic TMP represents a common reason for evaluation in the ED. Despite common warnings regarding risk of injury to the tympanic membrane with use of a cotton-tipped applicator, it is still a major cause of traumatic TMPs. Other injury mechanisms also play an important role in the teenage and young adult populations.