---
title: "How to Draw Tympanic Membrane Perforations"
description: "A practical guide for MBBS and ENT students on representing different types of tympanic membrane perforations in clinical cases and viva exams."
source: "The ENT Resident"
author: "Dr. Mausumi Das"
canonical_url: "https://www.theentresident.com/ent-notes-lectures/draw-tympanic-membrane-perforations"
categories: ["Otology", "Drawings in ENT"]
video: "https://www.youtube.com/watch?v=8TUvEojWaoE"
image: "https://media.theentresident.com/og-images/draw-tympanic-membrane-perforations.png"
---

# How to Draw Tympanic Membrane Perforations

A practical guide for MBBS and ENT students on representing different types of tympanic membrane perforations in clinical cases and viva exams. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=8TUvEojWaoE

## 🖍 How to Draw Tympanic Membrane Perforations

If you've already learned how to draw a **normal tympanic membrane** (check the previous post if not), the next skill you need for **long cases, short cases**, and **viva examinations** is knowing **how to depict tympanic membrane perforations**.

This guide breaks down all the major types of perforations you may observe in **CSOM (Chronic Suppurative Otitis Media)** and other conditions — and how to draw them accurately in your clinical notes.

### 🎯 Why You Need to Master This

When you're presenting a case of **CSOM with perforation**, it's important to:

- Identify the **type and location** of perforation
- Accurately **draw** it on a tympanic membrane diagram
- Differentiate between **safe and unsafe** types
- Describe **traumatic vs pathological** perforations

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### 📍 Types of Tympanic Membrane Perforations

1- **Small Central Perforation (Anterosuperior Quadrant)**

- Draw a small circle in the **anterosuperior quadrant**
- Represents a minor, centrally located defect

2- **Medium Central Perforation (Anterior Quadrants)**

- Perforation involves **anterosuperior** and **anteroinferior** quadrants
- Draw a larger circle across both anterior quadrants

![Small and Medium Central Perforation](https://media.theentresident.com/post-images/small-and-medium-central-perforation.png)

3- **Large Central Perforation (Involving 3 Quadrants)**

- Involves:
  - Anterosuperior
  - Anteroinferior
  - Posteroinferior quadrants
- Not involving the annulus

4- **Subtotal Perforation**

- Involves **almost entire pars tensa**
- 🧠 *Key Point*: **Tympanic annulus is intact**
- Draw a large perforation sparing the annular rim

![Large Central Perforation and Subtotal Perforation](https://media.theentresident.com/post-images/large-central-perforation-and-subtotal-perforation.png)

5- **Total Perforation**

- **Complete loss** of pars tensa including the annulus
- No tympanic membrane landmarks visible
- Draw as **entire membrane missing**

6- **Pinhole Perforation**

- Tiny perforation visible in one quadrant
- Represent with a **small dot** wherever located

![Total Perforation and Pinhole Perforation](https://media.theentresident.com/post-images/total-perforation-and-pinhole-perforation.png)

### ⚠ Unsafe Types of Perforation

These are considered dangerous due to risk of **cholesteatoma** formation:

7- **Attic Perforation**

- Seen in the **pars flaccida** (above the lateral process of malleus)
- Draw in the **upper region (attic area)**

8- **Marginal Perforation**

- Edge of perforation **extends up to the annulus**
- Draw close to the **periphery of tympanic membrane**

![Attic Perforation and Marginal Perforation](https://media.theentresident.com/post-images/attic-perforation-and-marginal-perforation.png)

### 💥 Traumatic Perforation

**Features:**

- **Ragged edges**
- Often **blood-stained or tinged**
- Caused by:
  - Barotrauma
  - Slap injury
  - Foreign body
- Draw irregular, jagged edges with blood tinge if needed

![Traumatic Perforation](https://media.theentresident.com/post-images/traumatic-perforation.png)

### 🔁 Multiple Perforations

- Seen in rare cases
- Draw **multiple small perforations** in different quadrants

![Multiple Perforations](https://media.theentresident.com/post-images/multiple-perforations.png)

---

### 🧾 Quick Summary

| Type | Key Features | Drawing Tip |
| --- | --- | --- |
| Small Central | Limited to 1 quadrant | Small circle |
| Medium Central | Involves 2 anterior quadrants | Medium circle |
| Large Central | Involves 3 quadrants | Large circle |
| Subtotal | Nearly entire pars tensa, annulus spared | Large perforation with rim intact |
| Total | Complete membrane loss | Entire TM missing |
| Attic | Pars flaccida region | Draw at upper TM |
| Marginal | Edge touches annulus | Draw at periphery |
| Traumatic | Ragged, blood-stained | Jagged outline |
| Multiple | Multiple small defects | Multiple dots |

---

### 🎓 Final Tips

- Always **mark quadrants** when drawing the tympanic membrane.
- Use **neat labels** for clarity during the presentation.
- Know how to **differentiate safe vs unsafe** perforations.

---

## About This Note

This free ENT note on How to Draw Tympanic Membrane Perforations was written by Dr. Mausumi Das and is paired with a corresponding video lecture.

Canonical page of this note: https://www.theentresident.com/ent-notes-lectures/draw-tympanic-membrane-perforations

When citing or referencing this content, please credit The ENT Resident and link to the canonical page above.

## Related Notes by Category

- Otology: https://www.theentresident.com/ent-notes-lectures/category/otology.md
- Drawings in ENT: https://www.theentresident.com/ent-notes-lectures/category/drawing-in-ent.md

## About The ENT Resident

The ENT Resident is an educational website and resource library created by Dr. Mausumi Das (MS ENT) for ENT residents, ENT postgraduates preparing for exams, and MBBS students.

Dr. Mausumi Das writes the notes, draws the diagrams, and records the lectures herself.

Browse all ENT notes and lectures on The ENT Resident: https://www.theentresident.com/ent-notes-lectures.md

## Medical-use Boundary

The ENT Resident provides educational material for medical learning and revision. It does not provide patient-specific medical advice, diagnosis, or emergency care, and it is not a substitute for evaluation by a qualified healthcare professional.

## More Resources

- Learn about the Premium ENT Notes, preview a complete sample, and find purchase options: https://www.theentresident.com/premium.md
- Premium note for this topic, How to Draw Tympanic Membrane Perforations: https://theentresident.gumroad.com/l/dizqm
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