In general, such perforations are caused by chronic suppurative otitis media. In addition to hearing loss, patients present with purulent drainage that subsides on antibiotic treatment. The perforation is then patched with a temporalis fascia graft
This dry perforation in the posteroinferior quadrant has ragged edges and to a certain extent, resembles traumatic perforations. The fragment of skin hanging in the center of the perforation was pulled out of the middle ear, where it was forming a cholesteatoma sac.