How can an eardrum perforation occur during otitis media?

In the context of otitis media, an eardrum perforation occurs primarily due to the buildup of pressure within the middle ear.12

When the middle ear becomes inflamed—often due to a bacterial or viral infection—fluid or pus accumulates behind the tympanic membrane. In cases of severe otitis media, the pressure exerted by this accumulating fluid can become intense enough to cause the membrane to tear or rupture.12

While some perforations may heal on their own, a failure of the membrane to close can lead to persistent hearing loss and an increased susceptibility to further infections or the development of cholesteatoma. In some clinical situations, a physician may intentionally puncture the tympanic membrane to drain fluid and relieve pressure, a procedure that typically heals quickly once the underlying condition is resolved.13