From the Guidelines
The management of tympanic membrane perforation primarily involves watchful waiting, as most perforations heal spontaneously within 1-3 months, and the use of non-ototoxic topical preparations is recommended when a perforation is known or suspected. When a patient has a known or suspected perforation of the tympanic membrane, careful examination and assessment are crucial to determine the best course of action 1.
Key Considerations
- Keep the ear dry by avoiding water entry, using cotton balls coated with petroleum jelly during showering, and avoiding swimming until healing is complete.
- Pain can be managed with acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) as needed.
- If discharge is present, topical antibiotic drops like ofloxacin (5 drops twice daily for 7-10 days) may be prescribed, but systemic antibiotics are generally unnecessary unless there are signs of infection spreading beyond the ear.
- Avoid inserting anything into the ear canal, including cotton swabs, to prevent further irritation or infection.
Follow-Up and Surgical Intervention
- Follow-up with an otolaryngologist is recommended after 4-6 weeks to ensure proper healing.
- If the perforation persists beyond 3 months or is large, surgical repair (tympanoplasty) may be considered, as the tympanic membrane's excellent blood supply and regenerative capacity may not be sufficient for larger perforations or those with inverted edges to heal without intervention 1.
Special Considerations
- In cases where the ear canal and auricle are tender or swollen, making it difficult to visualize the tympanic membrane, tympanometry can sometimes be helpful in establishing the presence of an intact tympanic membrane, but this should be done with caution to avoid causing undue pain or discomfort.
- Children with tympanostomy tubes are a special instance, and a patent tube should be assumed to be present within the tympanic membrane of any individual who had it placed less than a year ago, unless the most recent examination preceding the episode has verified that the perforation has closed 1.
From the Research
Management of Tympanic Membrane Perforation
The management of tympanic membrane perforation typically involves keeping the affected ear dry and may include:
- Suctioning out blood, purulent secretions, and other debris from the canal 2
- Avoiding irrigation and pneumatic otoscopy 2
- Oral and topical antibiotics for perforations related to acute otitis media 2, 3
- Paper-patching procedure for traumatic tympanic membrane perforations 3
- Antibiotic and steroid irrigation of the middle ear for active chronic otitis media with small perforation and pulsatile discharge 4
Conservative Management
Conservative management of tympanic membrane perforation can be effective, with most small perforations resolving spontaneously 2, 5. In some cases, patients may be prescribed oral antibiotics, such as amoxicillin/clavulanic acid, for 7 days 3. The use of antibiotic and steroid drops has also been shown to be effective in managing chronic suppurative otitis media with small perforations and pulsatile discharge 4.
Referral to Otolaryngologist
Referral to an otolaryngologist may be necessary to evaluate traumatic perforations associated with vertigo or significant hearing loss, perforations from chronic otitis media, or perforations from acute otitis media that do not heal within one month 2. In some cases, patients may require further treatment, such as tympanoplasty, to repair the perforated tympanic membrane 4.
Treatment Outcomes
The outcomes of treatment for tympanic membrane perforation can vary, with some studies showing high closure rates for perforations treated with paper-patching or antibiotic therapy 3. However, the effectiveness of treatment can depend on various factors, such as the size and location of the perforation, as well as the presence of any underlying conditions, such as otitis media 2, 6.