What antibiotics are used to treat a ruptured eardrum (tympanic membrane perforation)?

Antibiotic Treatment for Ruptured Eardrums

For ruptured eardrums with infection or discharge, topical antibiotic ear drops (particularly fluoroquinolones like ofloxacin or ciprofloxacin-dexamethasone) are the preferred first-line treatment rather than systemic antibiotics. 1, 2

Antibiotic Selection Based on Presentation

For Perforated Eardrums with Discharge/Infection:

1. First-line treatment:

   • Topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone) 1
   • Dosing: Apply drops in ear canal twice daily for up to 10 days
   • After application, "pump" the tragus (flap of skin in front of ear canal) to help drops enter the ear tube

2. When to avoid systemic antibiotics:

   • For uncomplicated perforations with discharge
   • When infection is limited to the ear canal 2

3. When to consider systemic antibiotics:

   • Infection extending beyond the ear canal
   • Patient has specific host factors (diabetes, immunocompromised state) 2
   • Severe systemic symptoms

For Traumatic Perforations:

• Most heal spontaneously without antibiotics 3
• Keep ear dry to prevent secondary infection
• Topical ofloxacin otic solution has shown excellent healing rates (97.6%) for large traumatic perforations 4

For Perforations Due to Acute Otitis Media:

• Treat with appropriate antibiotics (oral amoxicillin or amoxicillin-clavulanate) 1
• Consider topical antibiotics if discharge is present

Important Precautions and Considerations

Avoid These Practices:

• Do not irrigate a perforated eardrum - can cause vertigo and infection 2
• Avoid aminoglycoside-containing drops (like neomycin) - risk of permanent sensorineural hearing loss 2
• Avoid alcohol-containing solutions - painful and potentially ototoxic 2
• Avoid unnecessary steroid-containing drops - may delay healing 2

Proper Administration:

• Clean external ear canal of discharge or debris before applying drops
• Position patient with affected ear upward for 3-5 minutes after application
• For self-administration, pull ear upward and backward (adults) or downward and backward (children)

Evidence for Topical vs. Systemic Treatment

Topical quinolone antibiotics are significantly more effective than systemic antibiotics for treating discharging ears with perforations:

• 3.21 times more likely to clear discharge at 1-2 weeks compared to systemic non-quinolone antibiotics 5
• 3.18 times more effective than systemic quinolones 5

Follow-up and Monitoring

• Examine patients within 3 months of initial diagnosis 2
• Follow periodically until complete healing occurs
• Perform audiometric testing at least 6 weeks after initial diagnosis 2
• Refer to otolaryngologist if:
  • Perforation doesn't heal within expected timeframe
  • Traumatic perforation with vertigo or significant hearing loss
  • Chronic perforation
  • Suspected ossicular chain disruption 2

Patient Instructions

• Keep ear dry - use earplug or petroleum jelly-coated cotton before showering
• Avoid swimming until cleared by physician 2
• Do not scratch or touch the ear
• Complete full course of prescribed antibiotics
• Return for follow-up as directed
• Seek immediate care if experiencing increased pain, vertigo, facial weakness, or fever

By following these evidence-based guidelines for antibiotic selection and administration, most perforated eardrums can be effectively managed with minimal complications and optimal healing outcomes.