Posterior TM perforations carry greater hearing loss: practical pointers for clinic
Reviewed by Yovina Khiroya-Morjaria

This single-centre prospective study of 100 adults with central pars tensa perforations examined how perforation size and quadrant relate to hearing loss. Using video-otoscopy to estimate perforation area and pure tone audiometry for thresholds, the authors found hearing loss in 96% of cases; posterior perforations were disproportionately associated with moderate–severe loss (≈58%) compared with anterior sites, and larger perforations correlated with worse PTA. For UK practice, the message is pragmatic: in patients with posterior quadrant perforations, set clearer expectations about the likelihood of a larger air-bone gap, prioritise earlier ENT review (especially if work or communication needs are pressing) and consider prompt surgical opinion where appropriate. For anterior, smaller perforations, conservative management and watchful waiting may be reasonable if the ear is otherwise dry and stable. The quadrant-specific emphasis also helps with counselling: posterior defects likely expose the round window more directly, reducing the normal phase differential and increasing conductive loss. Limitations include the single-centre design, absence of frequency-specific ABG analyses (high-frequency vs. low-frequency effects) and no formal ossicular chain status, which can confound size/location –loss relationships. Nonetheless, the quadrant signal is clinically intuitive and aligns with previous work. In everyday clinics, documenting size and precise location with photographic otoscopy, and linking this to functional impact in the discussion, will improve decision-making and patient expectations.

Assessment of hearing loss severity in relation to the position and extent of tympanic membrane perforation.
Arivazhagan GB, Raj KP, Srinivasa N, et al.
HEAR BALANCE COMMUN 
2025;23(3):120–5.