|Year : 2021 | Volume
| Issue : 1 | Page : 1-5
Pattern of traumatic tympanic membrane perforations in Benin city
Ufuoma Maris Efole1, Amina Lami Okhakhu2
1 Department of Ear, Nose and Throat, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria
2 Department of Ear, Nose, Throat, Head and Neck, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||06-Feb-2021|
|Date of Decision||13-May-2021|
|Date of Acceptance||19-May-2021|
|Date of Web Publication||30-Jun-2021|
Ufuoma Maris Efole
Department of Ear, Nose and Throat, Delta State University Teaching Hospital, Oghara, Delta State
Source of Support: None, Conflict of Interest: None
BACKGROUND: Trauma is a recognised aetiological factor in tympanic membrane (TM) perforation. TM perforation remains a common presentation and is often with deleterious sequelae.
AIM: The aim of this study is to determine the aetiological factors responsible for TM perforation as well as traumatic TM perforation (TTMP) among patients seen in the University of Benin Teaching Hospital (UBTH), Benin City.
METHODS: A 2-year retrospective review of first time attendees with otologic symptoms at the ENT, H and NS Department of UBTH from January 2017 to December 2018. Data retrieved included age, sex, presenting complaints, aetiologic factors, examination findings, treatment and outcome. Data were analysed using the SPSS® software version 22.
RESULTS: A total of 240 patients with TM perforations were seen. There were 107 (44.6%) males and 133 (55.4%) females giving a male:female ratio of 1:1.2. The age range was 2–85 years with a mean age of 32.63 (standard deviation ± 20.99) years. The aetiology for TM perforation was infective in 198 (82.5%) while traumatic in 42 (17.5%). Among the cases of traumatic perforations occurring in 42 patients (24 males and 18 females), assault from unknown assailant was the most common cause 13 (22.2%) occurring mostly in males. Domestic assault was the most common cause of TTMP in females, accounting for 10 (14.8%) of the 11 cases (18.5%) while self/parent inflicted was the most common cause in children.
CONCLUSION: The spate of violence in the society is on the increase and the presence of TTMP may be an indicator. Males usually present due to assault from strangers/security agents. Domestic violence is almost exclusively responsible for TTMP in females.
Keywords: Infection, perforation, traumatic, tympanic membrane, violence
|How to cite this article:|
Efole UM, Okhakhu AL. Pattern of traumatic tympanic membrane perforations in Benin city. J Med Womens Assoc Niger 2021;6:1-5
|How to cite this URL:|
Efole UM, Okhakhu AL. Pattern of traumatic tympanic membrane perforations in Benin city. J Med Womens Assoc Niger [serial online] 2021 [cited 2021 Sep 27];6:1-5. Available from: http://www.jmwan.org/text.asp?2021/6/1/1/319615
| Introduction|| |
Tympanic membrane (TM) perforation is a common otologic diagnosis made in patients seen by an otorhinolaryngologist. It cuts across all age groups and sexes.
The TM is a clear and transparent membrane that forms a partition between the external acoustic meatus and the middle ear cavity. It is approximately 10 mm tall, 8 mm wide and 0.1 mm thick in adults, and it is made up of three layers: an outer epithelial layer continuous with the skin of the external acoustic meatus, a middle fibrous layer and an inner mucosal layer continuous with the mucosa of the middle ear., It serves to conduct sound across the middle ear and to protect the middle ear cleft from infection. An intact TM is required for normal hearing because of the vital role it plays in the transmission of sound from the external to the middle ear.,
A perforated TM occurs when there is a defect in the normally continuous TM sheath. When this happens there is a communication between the external ear and the middle ear. This can result in disturbances with sound perception and hearing loss as the surface area for transmission of sound to the middle and inner ear has been reduced.
TM perforation occurs commonly as a result of infection of the middle ear. Other causes include trauma and middle ear tumours. Trauma may be in the form of direct traumatic force, acoustic trauma, barotraumas or iatrogenic injuries. Trauma to the ear can range from pinna lacerations/avulsion, TM perforation to more severe forms such as temporal bone fractures and ossicular chain disruptions. This study is focused mainly on trauma as an aetiological factor in TM perforations. Some of these injuries to the ears, especially those caused by trauma heals spontaneously but most will require treatment to avert the adverse effect of a permanent and discharging TM perforation. There seem to be an increase in trauma as an aetiological factor in TM perforation as compared with previous studies. However, its economic impact in our society still remains undetermined. We seek to determine the aetiological factors and pattern of traumatic TM perforation (TTMP) among patients seen at the Ear, Nose, Throat, Head and Neck Surgery Department of the University of Benin Teaching Hospital (UBTH), Benin City.
This study aims to determine the aetiology of TTMP in different age groups.
| Methods|| |
It was a 2-year retrospective review of medical records of first time attendees with otologic symptoms at the Ear, Nose and Throat Department of UBTH, Benin City, Nigeria, from January 2017 to December 2018. The inclusion criteria were those with TM perforation irrespective of the aetiological factor while those without TM perforation were excluded. Ethical clearance was obtained from the Ethics and Research Committee of UBTH. The medical records of all patients seen during the study period with a clinical finding of TM perforation were retrieved. Data extracted from the records included age, sex, clinical presentation, mechanism of injury, examination findings, clinical diagnosis, treatment and outcome. The data were collated and analysed using the SPSS® software version 22.0 (Chicago, IL, USA).
Descriptive data were presented using frequency tables and charts. The categorical variables were presented as proportions and continuous variables were described as means or medians as applicable. Analytic statistics were presented as tabular and graphical data and assessed for discrete variables with the Chi-square test, and for continuous variables with independent sample t-test. The level of statistical significance was taken as P < 0.05.
| Results|| |
A total of 240 patients had TM perforation during the period under review. There were 107 (44.6%) males and 133 (55.4%) females with a male-to-female ratio of 1: 1.2. The age range was 2–85 years, with a mean age of 32.63 (standard deviation ± 20.99) years. The age group most commonly affected was 11–20 years accounting for 47 (19.6%) of the patients [Figure 1]. The TM perforation was bilateral in 79 (32.9%) while the right ear was affected in 95 (39.6%) of the patients and the left ear was affected in 66 (27.5%) [Table 1].
|Figure 1: Age and sex distribution of tympanic membrane perforation among patients|
Click here to view
|Table 1: Laterality and aetiology of tympanic membrane perforation in the patients|
Click here to view
In terms of aetiological factors, infection (consisting of both chronic suppurative otitis media [CSOM] and acute suppurative otitis media [ASOM]) was responsible for TM perforation in 198 (82.5%) of the patients while trauma accounted for 42 (17.5%) of the cases. Among the infective causes of TM perforation, ASOM was diagnosed in 4.2% of the patients while 78.3% has CSOM [Table 1].
The total number of patients with TTMP was 42. Of this number, 24 (57.1%) were male and 18 (42.9%) were female [Table 2], with a male: female of 1.33:1. The left ear was mainly involved in TTMP occurring in 34 (81.0%) of cases [Table 1].
|Table 2: Age and sex distribution of traumatic tympanic membrane perforation|
Click here to view
There was no statistical significant association between sex and the age distribution of the patients with traumatic tympanic perforation, P = 0.073 [Table 2].
Various forms of assaults in the form of domestic violence, teacher/lecturer, security personnel and fights with strangers and assailants were the major cause of TTMP occurring in 35 (83.3%) of the 42 cases. Assaults from strangers/assailants were seen in 13 (31%) of the cases. Of this number, 12 were in males. The mean age of TTMP caused by assault from strangers is 27 ± 0.0 years [Table 3]. Domestic assault from a significant partner was seen in 11 (26.2%) of the cases, of which 10 were in females. Assault by security personnel and teachers was responsible for 4 (9.5%) and 3 (7.1%), respectively. The remainder causes of TTMP were as a result of road traffic accident, iatrogenic causes from health personnel while performing ear syringing and self/parent-inflicted injury when foreign bodies were inserted into the ears [Table 4]. Two of the five reported cases of self/parent-inflicted resulted from their mothers attempting to clean the ears of the child with cotton buds while three cases were as a result of the children inserting a foreign object into their ears.
|Table 3: Unadjusted binary logistic regression on predictors for traumatic tympanic perforation among males|
Click here to view
|Table 4: Mechanisms and types of traumatic perforations according to gender|
Click here to view
Logistic regression analysis showed that with unit increase in age, participants have 1.004 times the odds of having traumatic perforation. This is actually negligible, so there is virtually no effect of unit increase in age on the likelihood of having traumatic tympanic perforation.
Females were less likely as compared to males to present with traumatic tympanic perforation (odds ratio: 0.609, confidence interval: 0.312–1.189; P = 0.196).
The mean age for the occurrence for TTMP due to domestic violence was 26.3 ± 1.6 years occurring mostly in women showing that most of them were young women within the reproductive age bracket. TTMP occurring as a result of RTA and fights occurred mostly in young and active males, as shown in [Table 5].
|Table 5: Mean age for traumatic tympanic membrane perforation in various mechanism of injury|
Click here to view
| Discussion|| |
TM perforation is a common pathology encountered by the otolaryngologist., Its incidence seem to be on the increase. The major effect of TM perforation is hearing loss. The most common aetiological factor implicated in TM perforation in our study was CSOM in 78.3% of participants. This has also been reported by other studies., The reason for this is probably the high incidence of poverty, malnutrition, overcrowding and poorly treated or untreated ASOM in children in developing countries. Younger age groups were mainly affected (10–20 years), as shown in Figure 1. This is in tandem with other studies.,, We found a slight female preponderance (55%) for overall cases of TM perforation as also reported by other studies., This has been explained by probably the better health-seeking behaviour of females when compared with males in developing countries.
For the overall cases of TM perforations, the right ear was more involved in the majority of cases (39.6%) and bilaterally in less than half of cases (32.9%). This is similar to the findings by other researchers in Nigeria.,
However, for cases of TM perforation caused by trauma, the left ear was involved in 34 (81.0%) of cases similar to the findings by other authors.,, This might be explained by the fact that most people are right handed and so an assailant would strike or slap the left ear with their right hand.
The prevalence of TTMP in this study is 17.5%. There appears to be an increase in the trend of TTMP when compared with a previous study from the same centre. Our study which was over a 2-year period yielded 42 cases of TTMP (21 cases/year) while the earlier study carried out over a 10-year (2003–2012) period yielded only 87 cases (8.7/year). Adegbiji et al. reported a TTMP in 142 (26.8%) of the 529 patients reviewed. The age groups involved in all the studies were the young and active who are more prone to trauma.
We observed a male preponderance (57.1%) in the cases of TTMP and this is similar to reports by other authors., This can be as a result of males being more involved in physical activities (higher risk taking) than females that might result in trauma. The most common mechanism of TTMP was from assault from strangers and unknown assailants with a higher number of males being affected. The mean age of TTMP caused by assault is 27 ± 0.0 years [Table 5]. This was also reported by similar studies.,, Sogebi et al. reported a mean age 33.8 years of TTMP while others reported age range of 29.2–33.6 years.,,
Women were more affected in the cases of traumatic TM secondary to domestic violence. Of the total of 11 patients affected, 10 (90.9%) were females. The perpetrator was the intimate partner and injury was from slaps to the ears and head. Lou et al. reported that over 50% of incidences of TTMP in women were caused by a slap or blow to the ear by a spouse or lover. The culture of silence in domestic violence does not also make it easy for victims to report. Those who were bold enough to report were taken lightly and offenders are not brought to book. The bill prohibiting violence against persons has been signed into law. What we hope for is its implementation.
Among children, ear instrumentation was the only aetiological factor accounting for all the cases reported. Similarly, Ologe et al. reported similar findings.
Iatrogenic causes and violence from security personnel was the least cause of TTMP accounting for 4.8% and 9.5% respectively. All the cases caused by security personnel were in males. This has also being cited by another study. This may be attributed to the spate of violence meted out by security operatives on young men in our environment based on unconfirmed suspicions of being involved in crimes. Security personnel melting punishment or corrective measures on suspects without due process is also condemnable as they are not at liberty to take laws into their hands even when dealing with condemned criminal.
Self/care-giver inflicted unintentional injuries made up a small but appreciable mechanism of injury caused by trauma (11.9%) making up most of the penetrating injuries. Several studies have also noted this., These were mainly from repeated and compulsive ear cleaning with objects such as cotton buds, keys, the sharp ends of pens and any objects that can fit into the external ear canal. This habit is dangerous and can result in severe consequences in extreme cases. It should be discouraged as the ear is a self-cleansing organ which is better left alone.
Most of the traumatic perforations will healed spontaneously when kept dry. The infection was not contained in three of the patients with TTMP who went on to develop CSOM. They were commence on topical ear drops and counseled on the need for myringoplasty. One of the patients with complication of CSOM is the only one who attends the outpatient clinic. The other 2 have not been in attendance.
| Conclusion|| |
TM perforation occurs in all age group and gender. The aetiology of TTMP varies among males and females, and also age group categories. Domestic violence is a significant aetiological factor in TTMP in females accompanied with its deleterious effects and should be condemned. In males, it is commonly from assault by strangers and occasionally from security personnel which is also to be discouraged. In children, it is commonly iatrogenic or self/parent inflicted.
When females present with TM perforation, thorough evaluation is essential to detect the signs of domestic violence to allow interventions to forestall its deleterious effects.
Limitation of the study
The true incidence of TM perforation in Benin City cannot be fully analysed as only cases presenting to UBTH were evaluated.
The aetiologic factors responsible for the TM perforations were self-reported and so the degree of under reporting or over reporting cannot be fully determined especially among incidences in children. As such cases caused by violence might be missed as they usually present with their parents who might be unwilling to report such violence because of fear of persecution or even scolding from health personnel.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dhingra PL. Diseased of the ear. In: Dhingra PL, Dhingra S, editors. Diseases of Ear, Nose and Throat. 4th
ed. New Delhi: Elsevier; 2007. p. 3-13, 33, 67.
Voss SE, Rosowski JJ, Merchant SN, Peake WT. Non-ossicular signal transmission in human middle ears: Experimental assessment of the 'acoustic route' with perforated tympanic membranes. J Acoust Soc Am 2007;122:2135-53.
Pickles JO. Physiology of hearing. In: Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.
, editors. Scott Brown's Otorhinolaryngology Head and Neck Surgery. 7th
ed., Vol. 3. London: Arnold; 2008. p. 3176-206.
Pickles OJ. Physiology of hearing. In: Browning GG, Gleeson M, Burton MJ, Clarke R, Hibbert J, et al.
, editors. Scott-Brown's Otolaryngology-Head and Neck Surgery. 7th
ed., Vol. 3. London: Arnold; 2008. p. 3178-81.
Kruger B, Tonndorf J. Tympanic membrane perforations in cats: Configurations of losses with and without ear canal extensions. J Acoust Soc Am 1978;63:436-41.
Ediale J, Adobamen PR, Ibekwe TS. Aetiological factors and dimension of tympanic membrane perforation in Benin City, Nigeria. Port Harcourt Med J 2017;11:55-9. [Full text]
Afolabi OA, Aremu SK, Alabi BS, Segun-Busari S. Traumatic tympanic membrane perforation: An aetiological profile. BMC Res Notes 2009;2:232.
Hamilton J. Chronic otitis media in childhood. In: Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, et al.,
editors. Scott Brown's Otorhinolaryngology Head and Neck Surgery. 7th
ed., Vol. 1. London: Arnold; 2008. p. 928-64.
Onyeagwara NC, Okhakhu AL, Braimah OE. A retrospective study of traumatic tympanic membrane perforation at the University of Benin Teaching Hospital, Nigeria. Ann Biomed Sci 2014;13:83-92.
Olowookere SA, Ibekwe TS, Adeosun AA. Pattern of tympanic membrane perforation in Ibadan: A retrospective study. Ann Ib Postgrad Med 2008;6:31-3.
Ibekwe TS, Ijaduola GT, Nwaorgu OG. Tympanic membrane perforation among adults in West Africa. Otol Neurotol 2007;28:348-52.
Buvinic M, Medici A, Fernandez E, Torres AC. Gender differentials in health. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Cleason M, Evans DB, et al.
, editors. Disease Control Priorities in Developing Countries. 2nd
ed. New York: Oxford University Press; 2006. p. 195-210.
Darley DS, Kellman RM. Otologic considerations of blast injury. Disaster Med Public Health Prep 2010;4:145-52.
Adegbiji WA, Olajide GT, Olajuyin OA, Olatoke F, Nwawolo CC. Pattern of tympanic membrane perforation in a tertiary hospital in Nigeria. Niger J Clin Pract 2018;21:1044-9.
] [Full text]
Sogebi OA, Oyewole EA, Mabifah TO. Traumatic tympanic membrane perforations: Characteristics and factors affecting outcome. Ghana Med J 2018;52:34-40.
Lou ZC, Yang J, Tang Y, Fu YH. Topical application of epidermal growth factor with no scaffold material on the healing of human traumatic tympanic membrane perforations. Clin Otolaryngol 2016;41:744-9.
da Lilly-Tariah OB, Somefun AO. Traumatic perforation of the tympanic membrane in University of Port Harcourt Teaching Hospital, Port Harcourt. Nigeria. Niger Postgrad Med J 2007;14:121-4.
Kraus F, Hagen R. The traumatc tympanic membrane perforation – Aetiology and therapy. Laryngorhinootologie 2015;94:596-600.
Sarojamma DS, Raj S, Satish HS. A clinical study of traumatic perforation of tympanic membrane. IOSR J Dent Med Sci 2014;13:24-8.
Ologe FE. Traumatic perforation of tympanic membrane in Ilorin, Nigeria. Niger J Surg 2002;8:9-12.
Yamazaki K, Ishijima K, Sato H. A clinical study of traumatic tympanic membrane v perforation. Nihon Jibiinkoka Gakkai Kaiho 2010;113:679-86.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]