• Cotton swab;
  • tympanic membrane perforation;
  • perilymphatic fistula;
  • Level of Evidence: 2b



To evaluate the indications for observation versus surgery in the management of cotton swab-induced tympanic membrane perforations (TMP).

Study Design:

Institutional review board-approved retrospective cohort study of 1,540 patients with a diagnosis of TMP from 2001 to 2010. Patients with a cotton swab injury were subdivided into two groups: observation and surgery.


Data collection included demographics, symptoms, surgery type, and pre- and postintervention audiometry. Successful outcomes were defined as healed TMP; resolution/improvement of vertigo, tinnitus, or facial nerve paralysis; and/or closure of the air-bone gap (ABG).


Fifty-four of 1,540 patients presented with a cotton swab-induced TMP. Four of the 54 patients (7.4%) underwent delayed surgical repair with 100% success. Preoperatively, one patient had a facial nerve paralysis and two had vertigo with confirmed perilymphatic fistulae (PLF). Postoperatively, the facial nerve paralysis resolved, and one patient had mild vertigo. Fifty of 54 patients opted to forego surgery with 35 patients available for follow-up. Thirty-four (97%) of the 35 patients had spontaneous healing. The average time to perforation closure was 1.75 months. Twelve of 35 patients had no ABG after healing.


Observation is an appropriate consideration for patients who have a TMP due to a cotton swab injury. Surgical intervention should be offered early when a PLF is suspected, or if facial paralysis, severe vertigo, and/or profound sensorineural hearing loss are present. As otolaryngologists, we should be reluctant to offer surgical intervention of an acute injury without significant symptoms as most patients will heal spontaneously within 2 months.