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Perforation of the Drum

Perforations are holes in the eardrum that usually result from purulent infections of the middle ear. They are classified as central perforations, which do not extend to the margin of the drum, and marginal perforations, which do involve the margin.

The more common central perforation is illustrated here. In this case a reddened ring of granulation tissue surrounds the perforation, indicating a chronic infectious process. The eardrum itself is scarred and no landmarks are discernible. Discharge from the infected middle ear may drain out through such a perforation, but none is visible here.

A perforation of the eardrum often closes in the healing process, as illustrated in the next photo. The membrane covering the hole may be exceedingly thin and transparent.


In the inferior portion of this left eardrum there is a large, chalky white patch with irregular margins. It is typical of tympanosclerosis: a deposition of hyaline material within the layers of the tympanic membrane that sometimes follows a severe episode of otitis media. It does not usually impair hearing, and is seldom clinically significant.

Other abnormalities in this eardrum include a healed perforation (the large oval area in the upper posterior drum) and signs of a retracted drum. A retracted drum is pulled medially, away from the examiner's eye, and the malleolar folds are tightened into sharp outlines. The short process often protrudes sharply, and the handle of the malleus, pulled inward at the umbo, looks foreshortened and more horizontal.

(Sources of photos: Normal- Eardrum—Hawke M, Keene M, Alberti PW: Clinical Otoscopy: ATextand Colour Arias. Edinburgh, Churchill Livingstone, 1984; Perforation of the Drum, Tympanosclerosis—Courtesy of Michael Hawke, MD, Toronto, Canada.)

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Serous Effusion

Serous effusions are usually caused by viral upper respiratory infections (otitis media with serous effusion) or by sudden changes in atmospheric pressure as from flying or diving (otitic barotrauma). The eustachian tube cannot equalize the air pressure in the middle ear with that of the outside air. Air is partly or completely absorbed from the middle ear into the bloodstream, and serous fluid accumulates there instead. Symptoms include fullness and popping sensations in the ear, mild conduction hearing loss, and perhaps some pain.

Amber fluid behind the eardrum is characteristic, as in this left drum of a patient with otitic barotrauma. A fluid level, a line between air above and amber fluid below, can be seen on either side of the short process. Air bubbles (not always present) can be seen here within the amber fluid.

Acute Otitis Media With Purulent Effusion

Acute otitis media with purulent effusion is caused by bacterial infection. Symptoms include earache, fever, and hearing loss. The eardrum reddens, loses its landmarks, and bulges laterally, toward the examiner's eye.

In this right ear the drum is bulging and most landmarks are obscured. Redness is most obvious near the umbo, but dilated vessels can be seen in all segments of the drum. A diffuse redness of the entire drum often develops. Spontaneous rupture (perforation) of the drum may follow, with discharge of purulent material into the ear canal.

Moving the auricle and pressing on the tragus do not cause pain in otitis media as they usually do in acute otitis externa. Hearing loss is of the conductive type. Acute purulent otitis media is much more common in children than in adults.

Bullous Myringitis

Bullous myringitis is a viral infection characterized by painful hemorrhagic vesicles that appear on the tympanic membrane, the ear canal, or both. Symptoms include earache, blood-tinged discharge from the ear, and hearing loss of the conductive type.

In this right ear, at least two large vesicles (bullae) are discernible on the drum. The drum is reddened, and its landmarks are obscured. Several different viruses may cause this condition.

(Sources of photos: Serous Effusion—Hawke M, Keene M, Alberti PW: Clinical Otoscopy: A Text and Colour Atlas. Edinburgh, Churchill Livingstone, 1984; Acute Otitis Media, Bullous Myringitis—The Wellcome Trust, National Medical Slide Bank, London, LJK. )

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