What is the treatment for a perforated tympanic membrane (TM)?

Treatment for Perforated Tympanic Membrane

For perforated tympanic membranes, the recommended treatment is topical application of non-ototoxic antibiotic drops such as ofloxacin 0.3% otic solution, which promotes healing while preventing infection. 1, 2

Initial Assessment and Classification

When evaluating a perforated tympanic membrane (TM), consider:

• Cause of perforation (traumatic vs. infectious)
• Size of perforation (small, medium, large)
• Location of perforation (anterior vs. posterior)
• Duration since injury
• Presence of complications (otorrhea, hearing loss)
• Patient factors (diabetes, immunocompromised state)

Treatment Algorithm

1. Acute Traumatic Perforations

• First-line treatment: Ofloxacin 0.3% otic solution

  • For patients ≥12 years: 10 drops (0.5 mL) twice daily for 14 days 1
  • For pediatric patients: 5 drops (0.25 mL) twice daily for 10 days 1
  • Application technique: Warm drops by holding bottle in hand for 1-2 minutes, position affected ear upward, instill drops, pump tragus 4 times, maintain position for 5 minutes 1

• Benefits of ofloxacin drops:

  • Significantly shortens healing time (13-14 days vs. 25-50 days with observation alone) 3, 4, 5
  • Improves closure rates for large perforations (97.6% vs. 79.2% with observation) 3, 4
  • Non-ototoxic, safe for use with non-intact tympanic membranes 2
  • Creates moist environment that promotes healing 4

2. Chronic Suppurative Otitis Media with Perforation

• Treatment: Ofloxacin 0.3% otic solution, 10 drops (0.5 mL) twice daily for 14 days 1
• Efficacy: 75-91% clinical cure rate in chronic suppurative otitis media with perforated TM 2

3. Adjunctive Treatments

For large perforations (>50% of TM surface):

• Option A: Gelatin sponge patching + ofloxacin drops (87.2% closure rate) 3, 5
• Option B: Ofloxacin drops alone (97.6% closure rate) 3

Factors Affecting Healing Outcomes

Poorer healing outcomes are associated with:

• Large perforation size 6
• Posterosuperior location of perforation 6
• Penetrating injuries 6
• Diabetes or immunocompromised state 7

Special Considerations

1. Patients with diabetes or immunocompromised state:

   • Higher risk for otomycosis and necrotizing otitis externa 7
   • May require systemic antibiotics in addition to topical therapy 7
   • Avoid irrigation of ear canal 7

2. Fungal infections (otomycosis):

   • If suspected, consider topical antifungal therapy with boric acid or acetic acid solutions 7
   • For refractory cases with perforated TM, oral antifungals like voriconazole, posaconazole, or itraconazole may be appropriate 7

3. Mechanical removal of debris:

   • When cerumen or debris is present, use micro-instrumentation under microscopic visualization rather than irrigation 7
   • Irrigation is contraindicated with perforated TM due to risk of infection, pain, or vertigo 7

Follow-up and Monitoring

• Re-evaluate at 2 weeks to assess healing
• If no improvement after 2-4 weeks, consider referral to otolaryngology
• Most traumatic perforations heal within 1 month with appropriate treatment
• For persistent perforations (>3 months), surgical intervention may be necessary

Common Pitfalls to Avoid

1. Using ototoxic antibiotic drops (e.g., aminoglycosides) in perforated TM
2. Irrigating the ear canal when TM is not intact
3. Failing to identify and manage underlying causes (e.g., chronic infection)
4. Delaying treatment, which can lead to longer healing times and lower closure rates

By following this treatment approach, most perforated tympanic membranes will heal successfully with minimal complications and optimal hearing outcomes.