Traumatic causes of tympanic membrane perforation include Insertion of objects into the ear canal purposely (eg, cotton swabs) or accidentally Concussion caused by an explosion or open-handed slap across the ear Head trauma (with or without basilar fracture) Longitudinal temporal bone fracture Sudden negative pressure (eg, strong suction applied to the ear canal) Barotrauma (eg, during air travel or scuba diving) Iatrogenic perforation from instrumentation during irrigation or foreign body or cerumen removal Penetrating injuries of the tympanic membrane may result in dislocations of the ossicular chain, fracture of the stapedial footplate, displacement of fragments of the ossicles, bleeding, a perilymph fistula from the oval or round window resulting in leakage of perilymph into the middle ear space, or facial nerve injury.