Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
KEY WORDS: tympanic membrane; ear drum; perforation; rupture; combat sports; boxing
AUTHOR CONTRIBUTIONS: NKS evaluated the boxers, conceived, drafted, and revised the manuscript.
STUDY FUNDING: No targeted funding reported.
DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine. He also serves as the Chief Medical Officer, New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.
DATA SHARING STATEMENT: the author has no additional data to share.
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Nitin K. Sethi, MD
Associate Professor of Neurology Comprehensive Epilepsy Center New York-Presbyterian Hospital Weill Cornell Medical Center
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Professional boxing is a popular combat sport carrying a high risk for acute and chronic traumatic brain injuries (TBIs) as well as injuries to the hands, shoulders, and eyes. Traumatic tympanic membrane perforation (TTMP) has not been well documented in the boxing medical literature as compared to neurological and orthopedic injuries commonly associated with the sport. In this case series 5 boxers with TTMP are described. The mechanism of injury, clinical presentation, management, and prognosis is discussed.
Five boxers with TTMP were identified during the course of professional boxing bouts from the period 2018-2020. The boxers varied in age from 20 to 35 years and from welterweight (147 lbs.) to heavyweight (200 lbs. and above) weight class. All the 5 boxers were men and the injury occurred during the bout (4 rounds to 10 rounds bouts). Two of the 5 boxers made the ringside physician aware of their injury during the fight itself (one in the 3rd round and the other in the 5th round). In one of these boxers, blood was seen oozing out of the left ear during the fight leading to the diagnosis of TTMP. The boxer did not complain of any symptoms and the fight was allowed to proceed after examination by a ringside physician. In the other 3 boxers the injury was documented during the post-fight physical examination when the boxer complained of symptoms suggestive of TTMP though retrospectively all the 5 boxers were able to identify the round during which the injury occurred and sometimes even the causative punch. The boxers used the following phrases to draw attention to their injury: “I felt my ear pop”, “I feel air whooshing through my ear”, “my ear hurts”. In none of the 5 boxers, was the fight stopped (by the boxer himself, his corner, referee, or the ringside physician) on account of the injury.
Post-fight battery operated otoscopic examination confirmed the diagnosis of TTMP in all 5 boxers. Blood was identified in the external ear canal in all 5 boxers. The type of perforation was central in 2 boxers and marginal in 3. The sides affected were left ear in 3 and right ear in 2. No boxer had bilateral TTMPs. Two boxers complained of decreased hearing in the affected ear though this was not formally tested. Neurological examination was non-focal in 4 boxers. Nystagmus was not identified. Post-fight one boxer was stable on his feet with eyes open but unable to maintain stance with eyes closed. His tandem gait was impaired.
All the 5 boxers were discharged home from the event venue itself with instructions to keep the affected ear dry. An average of 30 days mandatory medical suspension was given with instructions to follow up with an otolaryngologist after discharge.
Traumatic tympanic membrane perforation is not a well-documented otolaryngological injury in professional boxing though it is not uncommon in this combat sport. Examination with a handheld battery- operated otoscope usually documents the injury. The mechanism of injury is usually a direct blow (punch) to the ear. Sudden forceful air compression occurring from a punch delivered by an open or partially open glove can lead to TTMP.1
The boxer may complain of acute pain, hearing loss, tinnitus or vertigo immediately following the perforation. In most cases the injury does not prevent the boxer from continuing to fight. If frank blood is noted to be oozing out of the ear during the bout, it is prudent to call a time out and examine the injured boxer to rule out a more serious etiology such as acute TBI with or without basilar fracture. Commonly the injury is documented during the post-fight physical examination when the boxer complains of pain in the ear, decreased hearing, tinnitus or when blood is noted in the external ear canal.
In the author’s experience TTMPs during boxing usually are not associated with dislocations of the ossicular chain, fracture of the stapedial footplate, displacement of the fragments of the ossicles or a perilymph fistula from the oval or round window causing leakage of perilymph into the middle ear space.
Treatment is usually supportive as most TTMPs heal on their own. The boxer should be advised to keep the ear dry. Routine antibiotic ear drops are unnecessary. Prophylaxis with oral broad-spectrum antibiotic such as amoxicillin 500 mg every 8 hours for 7 days and antibiotic ear drops are necessary if contaminants may have entered through the perforation as occurs in dirty penetrating injuries. 2
The boxer should be given a medical suspension and instructed to follow up with an otolaryngologist. Surgery is indicated for a perforation persisting greater than 2 months. Disruption of the ossicular chain may result in persistent conductive hearing loss necessitating surgical exploration and repair.
Traumatic tympanic membrane perforation is a not so uncommon otolaryngological injury in boxing. Early identification and proper management ensure a good outcome in most fighters.