From the Guidelines
Initial management of a perforated eardrum involves keeping the ear dry, avoiding water exposure, and preventing infection, with the use of non-ototoxic topical preparations recommended when the tympanic membrane is perforated, as stated in the 2014 clinical practice guideline on acute otitis externa 1. The goal of initial management is to promote healing, prevent infection, and minimize complications.
- Patients should be instructed to place a cotton ball coated with petroleum jelly in the outer ear canal during showering and to avoid swimming until healing occurs.
- Antibiotic ear drops, such as ofloxacin, may be prescribed if there is evidence of infection or discharge, but oral antibiotics are generally not necessary unless there is significant infection spreading beyond the ear canal 1.
- Pain management with acetaminophen or NSAIDs is often sufficient, and patients should be advised against cleaning their ears with cotton swabs or other objects, as this can worsen the injury.
- Follow-up evaluation is recommended after 4-6 weeks to assess healing, and surgical repair (tympanoplasty) is typically considered only if the perforation persists beyond 3 months or if it is very large. It is essential to note that the presence of a nonintact tympanic membrane limits the options available for cerumen removal, and mechanical removal of cerumen is the preferred technique when the ear drum is not intact, as highlighted in the 2008 clinical practice guideline on cerumen impaction 1. However, the most recent and relevant guideline for managing a perforated eardrum is the 2014 guideline on acute otitis externa, which emphasizes the importance of using non-ototoxic topical preparations and avoiding systemic antimicrobials as initial therapy for uncomplicated cases 1.
From the Research
Initial Management for Perforated Eardrum
The initial management for a perforated eardrum (tympanic membrane perforation) involves several key steps:
- Keeping the ear dry to prevent infection, as perforation predisposes to infections 2, 3
- Avoiding irrigation and pneumatic otoscopy, as these can exacerbate the condition 3
- Carefully suctioning out blood, purulent secretions, and other debris from the canal 3
- Describing the perforation size and location 3
Treatment Approaches
Treatment approaches vary depending on the cause of the perforation:
- For traumatic perforations, most small perforations resolve spontaneously, and the affected ear should be kept dry 3, 4
- For perforations related to acute otitis media, oral and topical antibiotics may be prescribed 3, 5
- For chronic perforation due to chronic middle ear infection or cholesteatoma, surgery is usually necessary 2
Referral to Specialist Care
Referral to an otolaryngologist (ENT specialist) may be necessary in certain cases:
- When alarming signs such as continuous pain, vertigo, or facial paralysis exist 2
- When the perforation persists 2
- For traumatic perforations associated with vertigo or significant hearing loss 3
- For perforations from chronic otitis media or perforations from acute otitis media that do not heal within one month 3