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Traumatic Tympanic Membrane Rupture in a Mixed Martial Arts Competition

2008; Lippincott Williams & Wilkins; Volume: 7; Issue: 1 Linguagem: Inglês

10.1097/01.csmr.0000308672.53182.3b

1537-8918

Jeffrey D. Fields, Douglas B. McKeag, John L. Turner,

Facial Nerve Paralysis Treatment and Research

HISTORY AND EXAM A previously healthy 40-yr-old mixed martial arts (MMA) competitor was participating in his 23rd professional bout, after which he had planned retirement from the sport. Early in the first round, he received a left hook to the right side of his head. He immediately appeared off balance and lunged for his opponent's legs in a defensive maneuver. His opponent easily evaded the lunge, which was misdirected, and responded with a counter move, placing the subject on his back. The opponent subsequently landed several fist strikes to the head and face, and the referee stopped the fight, declaring it a technical knock out (TKO). The subject was able to stand to his feet immediately without assistance and participated in the ring ceremony declaring his opponent the victor. He then gave a brief speech declaring his retirement. At this time, the ringside physician noted blood on the right side of the subject's head, but he appeared to have normal mental status and no further disequilibrium. A complete evaluation was not performed until he had returned to his dressing room. When first questioned in his dressing room, the subject stated that he thought something might be wrong with his ear. He described an acute onset of severe vertigo after receiving the initial left hook described above. He reported that these symptoms quickly resolved and were no longer present at the time of the exam. He denied any feelings of confusion or presyncope at the initial incident or at the time of the exam. He had a history of previous injury to the pinna resulting in a chronic auricular hematoma and scarring. The physical exam revealed a normal mental state with no focal neurological findings, other than subjectively decreased hearing on the right. The right ear had a large chronic auricular hematoma with blood covering the auricle as well as visible in the ear canal. Visualization with an otoscope revealed a vertical tympanic membrane laceration located at the three o'clock position. No blood was visualized behind the tympanic membrane, although there was blood in the auditory canal. Scratch test revealed decreased but present hearing on the right. MEDICAL COURSE The subject was diagnosed with a traumatic rupture of the tympanic membrane. He was given non-steroidal anti-inflammatory drugs for pain and instructed to follow up with his primary care physician the next day and avoid getting any fluid in the ear. He decided not to seek medical follow-up and had continued slight bleeding from the ear canal until day 5 and had a full subjective return of hearing at day 7. There were no further vertiginous symptoms, and he denied any headache or other concussive symptoms. DISCUSSION Although a mild traumatic brain injury is the most common cause of loss of balance of a MMA competitor, the occurrence of vertigo without associated confusion should lead the ringside physician to consider the diagnosis of traumatic rupture of the tympanic membrane. Traumatic tympanic membrane (TM) rupture also is seen in non-combative sports such as water skiing, diving, and surfing because of contact with the surface of the water and in scuba diving due to barotrauma. The majority of traumatic TM perforations heal spontaneously in a few days to several months (1). Generally, the prognosis is poorer in patients with persistent eustachian tube dysfunction or with a history of chronic infections because of weakening of the TM. The first consideration in evaluation of a TM perforation is whether it warrants urgent consultation with an otolaryngologist. Generally, five situations call for such consultation: persistent vertigo (especially if associated with nystagmus), sensorineural hearing loss, severe tinnitus, active and significant bleeding, or facial paralysis. Persistent vertigo, sensorineural hearing loss, and severe tinnitus may indicate inner ear involvement. Transient vertigo can be caused by the temporary change in pressure in the middle ear, but in cases of vertigo in patients who have been scuba diving, the physician should consider inner ear decompression illness in the differential diagnosis. Situations that are less urgent but warrant the relatively early intervention of an otolaryngologist include significant conductive hearing loss (as may be seen with ossicular discontinuity) and significant debris or blood in the middle ear. This material should be promptly removed by microscopic suctioning (2). An outline of routine treatment of traumatic TM perforation is shown in the figure (3-5).Figure: Management of traumatic tympanic membrane (TM) rupture.CONCLUSION A mild traumatic brain injury is the most likely cause of disequilibrium occurring during MMA or similar combative sport competition. All competitors with symptoms should be thoroughly evaluated so this injury can be properly diagnosed and to establish appropriate follow-up for safe return to play. A less common cause of disequilibrium is TM perforation, which is a potentially serious condition and can occur during MMA competitions as well as other non-combative sports. One of the most important aspects of primary care for perforations is deciding which patients need to be referred and how urgently they need to be referred. There are several indications for surgical repair, but most cases can be managed with conservative care and require no referral. Given that the presence of a traumatic brain injury does not rule out the possibility of a traumatic TM rupture as well, an otoscopic ear exam should be standard post-fight evaluation of all fighters sustaining contact injuries to the head or face. This will aid in recognition of tympanic rupture, as well as other bony injuries involving the auditory canal.