Tympanic membrane perforation (TMP) represents one of the most common otologic conditions encountered in clinical practice and is a significant cause of conductive hearing loss worldwide. The tympanic membrane plays a vital role in the middle ear transformer mechanism by transmitting sound vibrations efficiently from the external auditory canal to the ossicular chain. Disruption of its structural integrity—whether due to infection, trauma, iatrogenic injury, or barotrauma—reduces the effective vibratory area and alters sound transmission dynamics, resulting in variable degrees of hearing impairment.[1,2] Although many perforations heal spontaneously, persistent defects may lead to progressive middle ear pathology and a higher burden of disability, underlining the need for early assessment and classification. The degree of conductive hearing loss following TMP is influenced by several factors, including perforation size, location, malleolar involvement, and the pneumatization of the middle ear and mastoid air cell system.[3,4] Larger perforations are associated with greater loss of the effective vibratory surface area, whereas perforations involving the posterior quadrants or abutting the manubrium may interfere with ossicular coupling and alter the physiologic phase differential between the oval and round windows.[5,6] Middle ear volume is another critical parameter, with smaller mastoid and middle ear spaces contributing to disproportionately greater air-bone gaps, even when perforations appear similar clinically.[7] These interacting determinants help explain why two perforations of nearly identical appearance may produce markedly different audiological outcomes. Previous studies have reported conflicting evidence regarding the influence of perforation location on hearing loss. While some investigators observed greater hearing impairment with posterior perforations or those contacting the malleus,[8] others found no significant correlation after adjusting for size and middle ear volume.[9] Additionally, the frequency pattern of hearing loss demonstrates characteristic variability, with the greatest losses typically occurring at lower frequencies and minimal impact around 2000 Hz—often described as an “inverted V” audiometric pattern.[10] These inconsistencies highlight the need for further well-designed clinical studies that account for all relevant anatomical and audiological variables. Given these gaps in the literature, the present study aims to systematically evaluate the correlation between TMP characteristics—specifically size, site, malleolar involvement, and mastoid pneumatization—and the degree and frequency of conductive hearing loss in patients with unilateral dry perforations. Understanding these relationships will aid clinicians in predicting hearing outcomes, planning surgical interventions, and counseling patients more effectively.

This prospective observational study was conducted in the Department of ENT at MGM Medical Hospital, Kamothe, Navi Mumbai, from March 2021 to September 2023. A total of 100 patients aged 18–50 years presenting with unilateral dry tympanic membrane perforation and conductive hearing loss were enrolled after obtaining informed written consent. Patients with active middle ear infection, bilateral or marginal perforations, previous ear surgery, tympanosclerosis, ossicular pathology, sensorineural hearing loss, or external ear disease such as otomycosis were excluded. Detailed clinical history, otoscopic examination, and documentation of symptoms such as otorrhea, otalgia, tinnitus, vertigo, and duration of illness were recorded using a pre-structured proforma. The size of the tympanic membrane perforation was measured under microscopic guidance using a Schirmer’s strip or graph paper and a 1 mm wire hook to determine the maximum vertical and horizontal diameters. The perforation area was calculated using the formula πR₁R₂, and perforations were categorized into small (0–9 mm²), medium (9–30 mm²), and large (>30 mm²). Perforation location was classified as anterior or posterior based on imaginary vertical and horizontal lines drawn through the handle of the malleus and umbo. Malleolar involvement was assessed based on whether the perforation contacted the manubrium. Mastoid pneumatization was evaluated using X-ray Schüller’s view and categorized as well-pneumatized or sclerotic. Hearing assessment was performed for all patients using pure tone audiometry (PTA) to determine air conduction (AC), bone conduction (BC), and the air–bone gap (ABG) across frequencies from 250 to 4000 Hz. Tuning fork tests (Rinne, Weber, and absolute bone conduction) were conducted as supportive bedside assessments. The relationship between perforation characteristics—size, site, malleolar involvement, and mastoid pneumatization—and the degree and frequency of conductive hearing loss was analyzed. Data were entered in MS Excel and statistically analyzed using SPSS version 25. Quantitative variables were expressed as mean ± standard deviation, qualitative variables as percentages, and associations were tested using appropriate statistical tests with a significance level of p < 0.05.

A total of 100 patients with unilateral dry tympanic membrane perforation were included in the study and analyzed for demographic characteristics, clinical profiles, perforation morphology, and audiometric outcomes. The findings describe the distribution of patients according to age, gender, laterality, and symptomatology, followed by detailed evaluation of perforation type, size, site, malleolar involvement, and mastoid pneumatization. Subsequent analyses assess the relationship between these perforation characteristics and the degree as well as frequency pattern of conductive hearing loss. Key observations from these variables are presented in the following tables and figures. Table 1. Baseline Demographic and Clinical Characteristics of the Study Population Frequency (n) Percentage (%) Gender Male 50 50.0% Female 50 50.0% Age (years) 18-30 35 35.0% 31-50 65 65.0% Side of Ear Perforation Left 65 65.0% Right 35 35.0% History of Ear Discharge Present 86 86.0% Absent 14 14.0% History of trauma Present 14 14.0% Absent 86 86.0% Hearing loss Present 86 86.0% Absent 14 14.0% Tinnitus Present 13 13.0% Absent 87 87.0% History of Ear Pain Present 42 42.0% Absent 58 58.0% Vertigo Present 4 4.0% Absent 96 96.0% Duration of Complaints Present 51 51.0% Absent 49 49.0% Table 1 summarizes the demographic and clinical characteristics of the 100 patients included in the study. There was an equal gender distribution, with males and females each contributing 50% of the sample. The majority of participants were between 31 and 50 years of age (65%), indicating that tympanic membrane perforation was more prevalent in middle-aged individuals. Left-sided perforations were more common (65%) compared to right-sided ones. A significant proportion of the patients (86%) reported a history of ear discharge, and an equal percentage presented with hearing loss, reflecting the chronic and symptomatic nature of the condition. Trauma accounted for perforation in only 14% of cases, suggesting that most perforations were due to infective causes. Tinnitus was reported by 13% of participants, while 42% experienced ear pain. Vertigo was uncommon, observed in only 4% of patients. The duration of complaints was nearly evenly split, with 51% having symptoms for ≤12 months and 49% for more than 12 months, indicating a mix of recent and longstanding cases. Table 2. Distribution of Patients According to Perforation Characteristics and Radiological Findings Frequency (n) Percentage (%) Type of Perforation Subtotal perforation 30 30.0% Moderate Central perforation 30 30.0% Small Central perforation 26 26.0% Large Central perforation 14 14.0% Site of Perforation Anteroinferior quadrant 78 78.0% Posterior inferior quadrant 68 68.0% Posterior superior quadrant 55 55.0% Anterosuperior quadrant 49 49.0% All quadrants 30 30.0% Site of Perforation Anteroinferior quadrant 78 78.0% Posterior inferior quadrant 68 68.0% Posterior superior quadrant 55 55.0% Anterosuperior quadrant 49 49.0% All quadrants 30 30.0% Cause of Perforation Chronic otitis media 86 86.0% Trauma 14 14.0% Malleolar involvement Yes 23 23.0% No 77 77.0% Size of perforation 0 – 9 mm2 (Group I) 30 30.0% 9 – 30 mm2 (Group II) 36 36.0% > 30 mm2 (Group III) 34 34.0% Findings on X-ray Pneumatised 61 61.0% Diploic 23 23.0% Sclerosed 16 16.0% Table 2 demonstrates the detailed distribution of tympanic membrane perforation characteristics among the study population. Subtotal and moderate central perforations were the most common types, each accounting for 30% of cases, while small and large central perforations contributed 26% and 14%, respectively. The anteroinferior quadrant was the most frequently involved site (78%), followed by posterior inferior (68%), posterior superior (55%), and anterosuperior quadrants (49%), with 30% of patients exhibiting involvement of all quadrants. Chronic otitis media was the predominant cause of perforation (86%), whereas trauma accounted for only 14% of cases. Malleolar involvement was present in 23% of patients, reflecting its role as a contributing anatomical factor. Perforation size was relatively evenly distributed across the three groups, with 30% in Group I (0–9 mm²), 36% in Group II (9–30 mm²), and 34% in Group III (>30 mm²). Radiological evaluation showed that the majority had a well-pneumatized mastoid (61%), whereas diploic and sclerosed mastoids were seen in 23% and 16% of patients, respectively. Table 3. Distribution of patients according to degree of hearing loss on Tuning fork test Right Ear Left Ear n % n % Degree of hearing loss on Tuning fork test Mild 24 24.0% 22 22.0% Moderate 18 18.0% 25 25.0% Severe 5 5.0% 19 19.0% Normal 53 53.0% 34 34.0% Degree of hearing loss on Pure tone audiometry Mild 26 26.0% 19 19.0% Moderate 16 16.0% 23 23.0% Severe 6 6.0% 25 25.0% Normal 52 52.0% 33 33.0% Table 3 compares the degree of hearing loss in both ears as assessed by tuning fork tests and pure tone audiometry (PTA). On tuning fork evaluation, more than half of the patients showed normal hearing in the right ear (53%), whereas only 34% had normal findings in the left ear. Mild and moderate hearing loss were more frequently observed in the right ear (24% and 18%) compared to the left ear (22% and 25%), while severe loss was notably higher in the left ear (19%) than the right (5%). PTA results showed a similar pattern, with normal hearing recorded in 52% of right ears and 33% of left ears. Mild and moderate losses were slightly more common in the right ear, whereas severe hearing loss was predominantly seen in the left ear (25% vs. 6%). Overall, the findings suggest a greater severity of hearing impairment in the left ear compared to the right across both assessment modalities. Table 4. Distribution of patients according to treatment Treatment Frequency (n) Percentage (%) Left type 1 Tympanoplasty 46 46.0% Right type 1 Tympanoplasty 24 24.0% TCA cauterization 10 10.0% Medication 8 8.0% Left type 1 Tympanoplasty with cortical mastoidectomy 6 6.0% Right type 1 Tympanoplasty with cortical mastoidectomy 5 5.0% Left type 3 Tympanoplasty 1 1.0%

In the present study, tympanic membrane perforation was observed predominantly among adults aged 31–50 years, consistent with patterns reported in earlier literature where chronic otitis media (COM) remains most common in the productive age group due to recurrent infections and untreated middle ear disease.[11] An equal gender distribution in our study aligns with reports by Saliba et al., who found no significant sex predisposition in TMP occurrence.[3] The majority of cases had a history of ear discharge and conductive hearing loss, reflecting the chronic inflammatory nature of the disease. Trauma contributed to a smaller proportion of perforations, echoing findings from Ahmad and Ramani, who also reported infective etiologies as the leading cause of TMP.[2] Perforation characteristics played a significant role in determining the degree of hearing impairment. In our study, anteroinferior quadrant perforations were most common, followed by posterior quadrant involvement. Similar patterns have been documented by Singh et al., who reported higher prevalence of anterior perforations while highlighting that posterior perforations often lead to greater hearing loss due to their proximity to the round window and altered sound transmission mechanics.[5] The distribution of perforation size in our sample showed nearly equal representation across small, medium, and large categories. Hearing loss increased progressively with perforation size, supporting the widely accepted relationship where larger perforations reduce the effective vibratory surface of the tympanic membrane and disrupt normal impedance matching.[4] Audiometric assessment demonstrated that moderate to severe hearing loss was more frequent in the left ear, a finding possibly influenced by the higher proportion of left-sided perforations in our sample. The correlation between perforation size and hearing loss observed in our study is consistent with the observations of Mehta et al., who demonstrated that the air–bone gap increases proportionately with perforation area, particularly at lower frequencies.[1] Our findings also align with the classical “inverted V pattern,” where maximal hearing loss is seen at 250–500 Hz, reflecting greater impact on low-frequency sound conduction in TMP. Radiological assessment indicated that most patients had a well-pneumatized mastoid; however, sclerosed mastoids were associated with larger perforations and greater hearing loss. This supports the concept that mastoid pneumatization influences middle ear acoustic space and contributes to conductive hearing outcomes.[7] Treatment patterns in our study showed that Type I tympanoplasty was the most commonly employed surgical intervention, consistent with global trends favoring tympanoplasty as the procedure of choice for central perforations with intact ossicular chains. The need for cortical mastoidectomy in a subset of patients aligns with established indications for managing sclerosed mastoids or persistent disease.[12] Overall, the findings reinforce established knowledge while providing clinically relevant insights into the relationship between perforation characteristics and hearing outcomes.

This study demonstrates that the degree of conductive hearing loss in patients with tympanic membrane perforation is significantly influenced by perforation size, location, malleolar involvement, and mastoid pneumatization. Larger perforations and those involving posterior quadrants or the malleus were associated with greater hearing impairment, particularly at lower frequencies. Most patients required surgical intervention, highlighting the chronic nature of the disease in this population. Understanding these correlations is essential for accurate clinical assessment, patient counseling, and selection of appropriate treatment strategies to optimize hearing outcomes.

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