What is the treatment for a ruptured tympanic membrane?

Management of Ruptured Tympanic Membrane

For a ruptured tympanic membrane, the recommended treatment is mechanical removal of debris under direct visualization using micro-instrumentation with adequate illumination, avoiding ear irrigation, and using topical non-ototoxic antibiotic preparations when infection is present. 1

Initial Assessment and Management

• Pain control: Provide appropriate analgesia based on severity

  • Mild to moderate pain: Acetaminophen or NSAIDs
  • Severe pain: Combination analgesics 1

• Examination technique:

  • Use adequate illumination and binocular microscope for stereoscopic magnification
  • Carefully suction blood, purulent secretions, and debris from the ear canal
  • Document perforation size and location 1, 2
  • AVOID irrigation and pneumatic otoscopy as these can cause complications 1, 2

Treatment Algorithm

1. For Uncomplicated Perforations

• Most small perforations resolve spontaneously 2
• Keep the affected ear dry 2
• Follow-up within 3 months of initial diagnosis 1
• Audiometric testing at least 6 weeks after initial diagnosis 1

2. For Perforations with Discharge or Infection

• Topical therapy: Use non-ototoxic topical preparations 1

  • For chronic suppurative otitis media with perforated tympanic membranes (patients ≥12 years):
    • Ofloxacin otic solution: Ten drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 3
    • Warm solution before instillation to avoid dizziness
    • Patient should lie with affected ear upward
    • Pump the tragus 4 times to facilitate penetration into the middle ear
    • Maintain position for five minutes 3

• Avoid systemic antibiotics unless there is:

  • Extension of infection beyond the ear canal
  • Presence of specific host factors (diabetes, immunocompromised state) 1

3. Special Considerations

• Early debridement and eversion of tympanic membrane flaps may be beneficial for blast ruptures 4
• Avoid ciprofloxacin/dexamethasone as it may delay healing of tympanic membrane perforations 5
• Ofloxacin has been shown to reduce healing time and increase rate of traumatic tympanic membrane perforation closure 6

Indications for Referral to Otolaryngologist

• Perforations that do not heal within one month 2
• Traumatic perforations associated with:
  • Vertigo
  • Significant hearing loss (>30 dB conductive loss suggests ossicular chain disruption)
  • Nausea and vomiting 1, 2
• Perforations from chronic otitis media 2
• Suspected ossicular chain disruption or cholesteatoma 1
• Patients with comorbidities (diabetes, immunocompromised states) 1

Follow-up Care

• Examine patients periodically until complete healing occurs 1
• Subsequent follow-up based on:
  • Perforation size
  • Location
  • Healing progress 1
• Patients with persistent symptoms (otorrhea, pain, hearing loss) warrant more frequent evaluation 1
• Advise patients with persistent perforations on appropriate water precautions 1

Pitfalls to Avoid

• Never irrigate a perforated eardrum - can cause caloric effects resulting in vertigo and potential infection 7, 1
• Avoid alcohol-containing solutions - can be painful and potentially ototoxic 1
• Avoid systemic antibiotics for uncomplicated cases 1
• Do not use pneumatic otoscopy with perforated tympanic membranes 2