What Is a Perforated Eardrum?
A perforated eardrum — also called a ruptured eardrum or tympanic membrane perforation — is a hole or tear in the thin membrane that separates your outer ear canal from your middle ear. The eardrum (tympanic membrane) is a remarkable structure: just 0.1 millimetres thick and roughly the diameter of a one-penny coin, yet it performs two absolutely essential jobs. First, it converts incoming sound waves into vibrations that travel through the three tiny bones of the middle ear — the malleus, incus and stapes — and onward into the fluid-filled cochlea. Second, it acts as a physical barrier, protecting the delicate middle ear from water, bacteria, and debris that would otherwise have direct access to structures critical for both hearing and balance.
When that membrane is breached, both functions are compromised. Sound transmission becomes inefficient, often producing a degree of hearing loss that varies according to the size and position of the hole. The protective barrier is also lost, raising the risk of repeated middle ear infections. Understanding why perforations happen, what to expect during healing, and when to seek treatment is important for anyone who suspects they may have one.
Perforated eardrums are more common than many people realise. NHS data suggests tens of thousands of patients are seen in ENT (ear, nose and throat) outpatient clinics each year for tympanic membrane perforations, and a significant proportion arise from the same middle ear infections that affect millions of UK adults and children annually.
Common Causes of a Perforated Eardrum
Perforations arise from several distinct mechanisms, and recognising the cause can help guide treatment decisions.
- Middle ear infection (otitis media): This is the single most frequent cause. When the middle ear fills with infected fluid, pressure builds behind the eardrum. In many cases the membrane ruptures spontaneously, releasing pus and immediately relieving pain. While distressing, this natural drainage often aids recovery — but the resulting perforation may not always heal on its own.
- Trauma: A sudden forceful impact to the ear — a slap across the ear with a cupped palm, a cotton bud pushed too far into the canal, or even an accidental headbutt — can generate a pressure spike sufficient to tear the membrane instantly. Foreign objects inserted into the ear canal remain a worryingly common cause, particularly in children.
- Barotrauma: Rapid changes in ambient pressure that overwhelm the Eustachian tube's ability to equalise pressure across the eardrum can cause it to rupture. This most commonly occurs during aircraft descent, scuba diving, or hyperbaric oxygen therapy. Congestion from a cold dramatically increases the risk.
- Blast injury: Explosive blasts — industrial accidents, airbag deployment, fireworks or military exposure — generate an intense pressure wave that can perforate one or both eardrums instantaneously. Blast perforations may be associated with other inner ear damage, including sudden sensorineural hearing loss and tinnitus.
- Surgical grommets: Ventilation tubes (grommets) inserted to treat chronic glue ear leave a small perforation that typically closes naturally after the tube falls out. Occasionally the hole persists and requires surgical repair.
- Chronic cholesteatoma: This destructive skin cyst in the middle ear can erode the eardrum and surrounding bone over time, creating a marginal perforation that carries a higher risk of serious complications.
Recognising the Symptoms
The symptoms you experience depend heavily on how the perforation occurred, how large the hole is, and whether infection is present alongside it.
In the immediate aftermath of a traumatic perforation — a slap, explosion, or sudden pressure change — you may notice a sharp pain in the ear followed by a feeling of fullness or pressure, a sudden reduction in hearing, and sometimes a brief high-pitched ringing. Blood-tinged or clear fluid may drain from the canal. Many people describe the moment as a loud "pop" followed by muffled hearing.
When a perforation results from a burst infection, the rupture is often preceded by several days of escalating earache. Paradoxically, the moment the eardrum perforates and discharges the accumulated pus, the pain eases dramatically. The drainage may be blood-stained at first and then become more purulent (pus-like) over subsequent days.
Persistent perforations — those that have not healed after two to three months — are often surprisingly asymptomatic between infections. The degree of hearing loss correlates roughly with the size of the hole. A small central perforation may produce only mild muffling of certain frequencies, while a large perforation affecting most of the membrane can cause a conductive hearing loss of 30-40 decibels — enough to make conversation in background noise genuinely difficult. Some people notice that their hearing actually improves temporarily when they hold their nose and gently pressurise, because the increased air pressure partially supports the membrane's movement.
Any episode of water getting into the ear — during showering, swimming, or even rain — tends to trigger an acute flare of pain, discharge, and worsened hearing, because water bypasses the eardrum's barrier and enters the unprotected middle ear directly.
How a Perforated Eardrum Is Diagnosed
Diagnosis is primarily clinical: a GP or ENT specialist will examine the ear canal using an otoscope — a handheld instrument with a light and magnifying lens — to visualise the eardrum directly. In many cases the perforation is clearly visible as a dark, irregular opening in an otherwise pearlescent membrane. The location of the hole matters clinically: a central perforation (within the pars tensa, away from the bony margin) has a lower complication risk and better healing prospects than a marginal or attic perforation near the edge of the membrane.
A thorough assessment will include at least one hearing test to establish how much functional impact the perforation is having. A standard hearing test (pure-tone audiometry) measures your hearing thresholds across a range of frequencies and will typically reveal a conductive hearing loss — a reduction in the ability to hear air-conducted sounds — while bone-conducted hearing remains relatively preserved. This pattern is characteristic of middle ear pathology.
Tympanometry — a quick, painless test that measures how the eardrum moves in response to small changes in air pressure — is also highly informative. A perforated eardrum produces a flat or absent tympanogram trace, quite different from the normal dome-shaped curve. This finding can help confirm the diagnosis and quantify the stiffness of the ossicular chain.
In complex cases, or before surgery is planned, additional assessments may include bone conduction testing to rule out concurrent sensorineural damage, and sometimes auditory brainstem response (ABR) testing to assess the integrity of the auditory nerve pathway — particularly relevant after blast injuries. If chronic ear infection or cholesteatoma is suspected, CT scanning of the temporal bone may be requested.
The Natural Healing Process — and Keeping the Ear Dry
The good news for most people with a newly perforated eardrum is that the body is well equipped to repair the damage without surgical intervention. Small to medium-sized central perforations — particularly those caused by infection or barotrauma rather than trauma — close spontaneously in the majority of cases. The NHS advises that most perforations heal within two to three months, with tissue migrating across the defect in a process similar to skin wound healing. Clinical audits suggest spontaneous closure rates of around 80-90% for small traumatic perforations when the ear is kept dry and infection-free.
Keeping the ear dry is the single most important thing you can do to support healing. Even a small amount of water entering a perforated ear creates an ideal environment for bacterial colonisation of the middle ear, which can precipitate an acute infection, delay or prevent healing, and extend the period of hearing loss. The practical implications are significant:
- Showering: Use a cotton wool ball coated in petroleum jelly (such as Vaseline) to plug the entrance to the ear canal. Alternatively, purpose-made silicone earplugs rated for swimmer use can create an effective water-tight seal.
- Hair washing: Tilt your head to keep the affected ear uppermost, and use a shower cap for additional protection.
- Swimming: Avoid all swimming — including baths rather than showers — until the perforation has fully healed and been confirmed closed by a clinician.
- Diving: Absolutely contraindicated until full healing is confirmed.
Your GP may prescribe antibiotic ear drops if there is active discharge (otorrhoea) alongside the perforation, helping to clear any infection and creating better conditions for healing. Oral antibiotics are not routinely required unless there is spreading infection. Pain relief with paracetamol or ibuprofen is appropriate in the early days.
You should also avoid blowing your nose forcefully while a perforation is present. The pressure generated can be transmitted up the Eustachian tube and through the middle ear, potentially dislodging early healing tissue. If you need to clear your nose, do so gently, one nostril at a time.
During the healing period, periodic review with your GP or an audiologist is advisable. A follow-up otoscopic examination at six to eight weeks will confirm whether closure is progressing. If you would like an assessment of your current hearing levels while awaiting resolution, an audiologist at Boots Hearingcare, Specsavers Audiology, or Hidden Hearing can perform a thorough hearing evaluation and help track your recovery.
When Surgery Is Needed: Myringoplasty and Tympanoplasty
If a perforation has not closed after three months of conservative management — or if it is large, marginal, or causing recurrent infections — surgical repair is usually recommended. The two main procedures are:
- Myringoplasty: A repair of the eardrum alone, using a small graft of tissue harvested from the patient's own body. The most common donor site is the temporalis fascia — the thin fibrous sheet overlying the temple muscle — which is accessed through a small incision behind or above the ear. The graft is placed across the perforation and held in position while new tissue grows over it. The procedure is performed under general anaesthetic and typically takes one to two hours.
- Tympanoplasty: A more extensive procedure that repairs the eardrum and addresses any damage to the ossicular chain (the three hearing bones). If the malleus, incus, or stapes have been eroded by chronic infection or cholesteatoma, they may need to be reconstructed or replaced with prosthetic implants to restore sound conduction.
Both procedures are well-established and are performed routinely in NHS ENT departments and private hospitals across the UK. Waiting times on the NHS can be lengthy — often six to eighteen months depending on urgency and local capacity. Patients referred to the NHS are encouraged to explore the NHS Referral to Treatment (RTT) pathway and may be eligible to choose from multiple providers under the NHS "choose and book" system.
Patients generally go home the same day or after one night in hospital. The ear is packed with dressings that dissolve over several weeks, and a follow-up appointment is made at around six weeks to assess early healing, with a formal hearing test typically performed at three to six months post-operatively.
Success rates for myringoplasty are high when performed by experienced surgeons. Large-scale UK audit data suggests overall graft take rates (successful closure) of around 85-90% for primary myringoplasty in patients without active infection at the time of surgery. Outcomes are somewhat lower in patients with a history of chronic otitis media, Eustachian tube dysfunction, or previous failed repairs. Hearing improvement follows in the majority of cases where closure is achieved — most patients experience a return to near-normal hearing thresholds, though in some a small residual conductive component persists.
Risks of Leaving a Perforated Eardrum Untreated
While many perforations are harmless and heal without consequence, a persistent untreated perforation carries genuine risks that should not be underestimated.
The most serious complication is the development of a cholesteatoma. This occurs when skin cells from the outer ear canal migrate inward through a marginal perforation and begin accumulating in the middle ear. Cholesteatomas are not malignant, but they are locally destructive: they release enzymes that erode bone, and if left untreated they can destroy the ossicles, spread into the mastoid bone behind the ear, damage the facial nerve, and in rare cases erode toward the brain, causing meningitis or intracranial abscess. The RNID and NHS both emphasise that cholesteatoma requires prompt surgical management and carries a meaningful recurrence rate even after surgery.
Chronic suppurative otitis media (CSOM) — persistent infection of the middle ear discharging through a perforation — affects an estimated 65-330 million people worldwide according to the World Health Organization, and is a significant cause of preventable hearing loss in the UK, particularly in children. The British Society of Audiology (BSA) notes that untreated CSOM can progressively damage the ossicular chain through repeated cycles of infection and inflammation, converting what began as a purely conductive hearing loss into a mixed loss with permanent sensorineural components.
Progressive hearing loss is therefore a real risk for those who delay treatment. Early assessment, appropriate management of recurrent infections, and timely surgical referral where indicated are the most effective ways to prevent long-term hearing impairment. Our guide to recognising the signs of hearing loss can help you identify whether your hearing has been affected.
Flying, Prevention, and Life After Healing
A common question is whether it is safe to fly with a perforated eardrum. The answer is nuanced. In the acute phase — particularly if there is active infection — flying is best avoided. Cabin pressure changes during ascent and especially descent can cause significant pain, and the risk of precipitating a new infection is elevated. However, once any acute infection has settled, many ENT surgeons take the view that flying with a stable dry perforation is not strictly harmful, and some patients even report that their perforation equalises pressure more easily than an intact eardrum because air can pass directly through the hole. You should always discuss this with your own clinician before booking travel, and inform the airline's medical team if you have any concerns.
Preventing perforations in the first place is largely about protecting your ears from the situations most likely to cause them. The NHS and RNID's guidance on protecting your hearing recommends:
- Never insert cotton buds, hairpins, or any other object into the ear canal. The ear is self-cleaning; inserting objects risks trauma and pushes wax deeper rather than removing it. If you have problematic ear wax, seek professional ear wax removal rather than attempting self-treatment.
- Treat ear infections promptly. Early antibiotic therapy for bacterial middle ear infections reduces the likelihood of spontaneous perforation.
- Equalise ear pressure consciously during air travel — swallow frequently during descent, chew gum, or perform the Valsalva manoeuvre (gently blowing against pinched nostrils). Avoid flying while congested if possible.
- Wear appropriate hearing protection in loud environments to reduce blast injury risk from industrial noise or recreational shooting.
- Divers should ensure their Eustachian tubes are functioning correctly before descending and should never dive with a cold or upper respiratory infection.
After a perforation has fully healed — whether spontaneously or surgically — we strongly recommend a formal hearing assessment to confirm your hearing has returned to its pre-perforation baseline. Tympanometry will confirm the eardrum is moving normally, and a pure-tone audiogram will map your thresholds across the speech frequency range. Understanding your audiogram results is straightforward with our guide to reading an audiogram. If any residual hearing difficulty persists, otoacoustic emissions (OAE) testing can assess whether the cochlear hair cells are functioning normally, helping to distinguish between ongoing middle ear dysfunction and inner ear involvement.
If you have had recurrent ear infections throughout your life, it is also worth asking your audiologist about baseline testing so that any future changes can be compared against a known starting point. The NHS hearing services available to you are explained in our guide to NHS hearing care. You can find a qualified audiologist near you using our local search — simply enter your postcode to see clinics with available appointments.