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

Treatment for Ruptured Tympanic Membrane

Most tympanic membrane perforations heal spontaneously within 1-2 months and require only conservative management, including keeping the ear dry and using topical non-ototoxic antibiotics if infection is present.

Initial Assessment

When evaluating a patient with a ruptured tympanic membrane (TM), consider:

• Cause of perforation (trauma, infection, etc.)
• Size and location of perforation
• Presence of infection or discharge
• Hearing status
• Associated symptoms (pain, vertigo, tinnitus)

Management Algorithm

1. Conservative Management (First-line approach)

• Keep the ear dry
  • Avoid water entry by using ear plugs or cotton balls coated with petroleum jelly during bathing/showering
  • No swimming until healed
• Avoid ear canal manipulation (no cotton swabs)
• Avoid pneumatic otoscopy and ear irrigation 1

2. Infection Management

• If infection is present (discharge, inflammation):
  • Use non-ototoxic topical antibiotics if the tympanic membrane is perforated 2
  • Recommended options:
    • Ofloxacin otic solution:
      • For patients ≥12 years: 10 drops (0.5 mL) twice daily for 14 days
      • For children: 5 drops (0.25 mL) twice daily for 10 days 3
    • Other non-ototoxic options include ciprofloxacin otic drops

IMPORTANT: Avoid aminoglycoside-containing drops (neomycin, gentamicin) as they can cause ototoxicity when exposed to the middle ear through a perforation 2

3. Pain Management

• Assess pain severity and recommend appropriate analgesics
• Options include:
  • Acetaminophen
  • NSAIDs (ibuprofen, naproxen)

4. Follow-up and Monitoring

• Re-evaluate in 2-4 weeks to assess healing
• Most small perforations will heal spontaneously within 1-2 months 1
• If no healing after 1 month, consider ENT referral 1

Special Considerations

Indications for Immediate ENT Referral

• Vertigo, nausea, or vomiting (suggests ossicular chain disruption)
• Significant hearing loss (>30 dB conductive loss)
• Facial nerve symptoms
• Traumatic perforations with concerning features
• Chronic perforations (>3 months)
• Perforations from chronic otitis media 1

Contraindicated Treatments

1. Ear irrigation - can force bacteria into middle ear and cause further damage
2. Pneumatic otoscopy - can enlarge perforation
3. Ototoxic topical antibiotics - can cause sensorineural hearing loss 2

Common Pitfalls to Avoid

1. Using ototoxic ear drops - Always use non-ototoxic preparations (quinolones) when the tympanic membrane is not intact 2

2. Prescribing systemic antibiotics unnecessarily - Topical antibiotics are generally more effective for otitis externa and infected perforations with minimal side effects compared to systemic antibiotics 2, 4

3. Failing to keep the ear dry - Moisture can delay healing and promote infection

4. Inadequate follow-up - Perforations that don't heal within 1 month should be referred to an otolaryngologist for further evaluation 1

By following these guidelines, most tympanic membrane perforations will heal without complications, preserving hearing and preventing chronic issues.