What is the treatment for a ruptured Tympanic Membrane (TM)?

Treatment of Ruptured Tympanic Membrane

For a ruptured tympanic membrane, conservative management with observation is the primary treatment approach, avoiding irrigation and using non-ototoxic topical preparations when medication is needed.

Initial Assessment and Management

When evaluating a patient with a ruptured tympanic membrane (TM), several key considerations guide management:

Immediate Care

• Carefully suction blood, purulent secretions, and debris from the ear canal 1
• Document the size and location of the perforation
• Avoid irrigation and pneumatic otoscopy as these can introduce infection or cause further damage 1
• Keep the affected ear dry to prevent contamination 1

Modifying Factors to Assess

• Presence of infection (otitis externa or media)
• Vertigo, nausea, or vomiting (suggesting ossicular chain disruption)
• Hearing loss severity (conductive loss >30 dB suggests ossicular disruption)
• Underlying conditions (diabetes, immunocompromised state) 2

Treatment Algorithm

1. For Clean, Uncomplicated Perforations

• Conservative management with observation is recommended
• Most small perforations heal spontaneously within 1-2 months 1, 3
• In a study of 80 patients with traumatic TM perforation, 56 out of 60 patients who completed follow-up recovered spontaneously 3
• Keep the ear dry during the healing period

2. For Infected Perforations

If Otitis Externa Present:

• Use non-ototoxic topical preparations 2
• When the tympanic membrane is perforated, avoid potentially ototoxic preparations that could damage the middle/inner ear 2
• For patients with perforated TM, mechanical removal of debris is preferred over irrigation 2

For Chronic Suppurative Otitis Media with Perforation:

• Ofloxacin otic solution is FDA-approved:
  • For patients ≥12 years: Ten drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 4
  • The solution should be warmed before instillation to avoid dizziness
  • Patient should lie with affected ear upward for five minutes after instillation 4

For Fungal Infections (Otomycosis) with Perforation:

• Use non-ototoxic topical preparations
• Topical therapy with boric acid, acetic acid, or azole cream may be effective 2
• For refractory cases, oral antifungals (voriconazole, posaconazole, or itraconazole) may be appropriate 2
• Combination therapy with ceftizoxime powder and clotrimazole ointment has shown effectiveness in treating otomycosis with TM perforation 5

3. Pain Management

• Assess pain severity and recommend appropriate analgesics 2
• NSAIDs or acetaminophen for mild to moderate pain
• Consider stronger analgesics for severe pain

Follow-up and Referral

• Follow-up within 2-4 weeks to assess healing
• Refer to otolaryngology if:
  • Perforation persists beyond 1 month 1
  • Significant hearing loss is present
  • Vertigo is associated with the perforation
  • Chronic otitis media is present 1
  • Surgical repair (tympanoplasty) is needed for persistent perforations

Important Cautions

• Never irrigate a perforated eardrum - this can introduce infection and cause severe pain or vertigo 2
• Avoid cotton-tipped applicators - these can cause further damage or leave cotton fibers in the ear canal 2
• Do not use ototoxic ear drops - these can cause permanent hearing loss when the middle ear is exposed 2
• Keep the ear dry during the healing process to prevent infection

Most tympanic membrane perforations heal spontaneously within 1-2 months with proper care and keeping the ear dry. Surgical intervention is only necessary for perforations that fail to heal or for large traumatic perforations with significant hearing loss.