Name of the Condition

• Unspecified Perforation of Tympanic Membrane, Right Ear
• Also known as: Eardrum perforation, Right tympanic membrane rupture.

Summary

A tympanic membrane perforation is a hole or tear in the eardrum— the thin tissue that separates the ear canal from the middle ear. This condition can result in hearing loss and increased vulnerability to ear infections.

Causes

• Trauma or injury to the ear (e.g., insertion of foreign objects, sudden pressure changes).
• Severe or chronic middle ear infections.
• Loud explosive noises or barotrauma (e.g., scuba diving, air travel).

Risk Factors

• History of ear infections.
• Participation in activities with sudden pressure changes (e.g., flying, diving).
• Exposure to loud, explosive sounds.

Symptoms

• Sudden ear pain or sharp ear ache.
• Drainage from the ear, possibly containing blood-like discharge.
• Tinnitus (ringing in the ear).
• Hearing loss in the affected ear.

Diagnosis

• Otoscopic examination by a healthcare professional to visually inspect the ear.
• Audiometry tests to assess hearing loss.
• Tympanometry to evaluate the functioning of the middle ear.

Treatment Options

• Observation: Minor perforations may heal on their own without intervention.
• Antibiotics: Used if an infection is present or to prevent infection.
• Surgical repair (Tympanoplasty): Recommended for large or persistent perforations to restore the integrity of the tympanic membrane.

Prognosis and Follow-Up

• Many cases resolve with conservative treatment. Regular follow-up appointments help track healing and assess hearing function.
• Surgical interventions often have a high success rate.

Complications

• Repeated ear infections.
• Permanent hearing loss.
• Cholesteatoma (an abnormal skin growth in the middle ear).

Lifestyle & Prevention

• Avoid inserting objects into the ear canal.
• Protect ears from loud noises with earplugs or noise-canceling headphones.
• Be cautious with activities that involve rapid changes in pressure.

When to Seek Professional Help

• Sudden ear pain or hearing loss.
• Persistent discharge from the ear.
• Symptoms of an ear infection that do not resolve or worsen.

Additional Resources

• American Academy of Otolaryngology-Head and Neck Surgery: www.entnet.org
• Hearing Health Foundation: www.hearinghealthfoundation.org

Tips for Medical Coders

• Verify the laterality of the tympanic membrane perforation; this code specifies the right ear.
• Ensure documentation clearly indicates whether the perforation is unspecified or has specific causes.
• Common coding errors include omitting laterality or using a code that implies a specific cause when not documented.