What is the management approach for tympanic membrane perforation?

Management of Tympanic Membrane Perforation

Most tympanic membrane perforations heal spontaneously within 2-3 weeks, though complete resolution of middle ear effusion can take up to 3 months in some cases, with specific management depending on the cause, size, and chronicity of the perforation. 1

Initial Assessment and Management

Evaluation

• Carefully suction blood, purulent secretions, and debris from the ear canal 2
• Document perforation size and location
• Avoid irrigation and pneumatic otoscopy to prevent further damage 2
• Assess for signs of ossicular chain disruption (vertigo, nausea, vomiting, conductive hearing loss >30 dB) 2

Acute Management

• Keep the ear dry - patients should:

  • Avoid water entry into the ear
  • Use earplugs or petroleum jelly-coated cotton when showering
  • Avoid swimming until cleared by a physician 1

• Pain management - provide appropriate analgesia:

  • Acetaminophen or NSAIDs for mild to moderate pain
  • Combination analgesics with opioids for severe pain 1

Treatment Based on Perforation Type

1. Acute Otitis Media with Perforation

• Topical antibiotics are first-line therapy:
  • Non-ototoxic fluoroquinolone drops (e.g., ofloxacin) are recommended 1
  • For chronic suppurative otitis media with perforated tympanic membranes in patients ≥12 years: Ten drops (0.5 mL) of ofloxacin instilled into the affected ear twice daily for fourteen days 3
  • For acute otitis media in pediatric patients (1-12 years) with tympanostomy tubes: Five drops (0.25 mL) instilled twice daily for ten days 3

2. Traumatic Perforation

• Most small traumatic perforations heal spontaneously within 1-2 months 4, 5
• Factors affecting healing:
  • Perforations in contact with the malleus have lower rates of spontaneous closure 5
  • Children demonstrate better spontaneous recovery rates than adults 4
• Treatment options that may accelerate healing:
  • Ofloxacin otic solution application (97.6% closure rate, mean healing time 13.12 days) 6
  • Gelatin sponge patching (87.2% closure rate, mean healing time 16.47 days) 6

Follow-up and Referral

Follow-up Schedule

• Re-evaluation within 48-72 hours if symptoms don't improve 1
• Follow-up within 3 months to assess healing 1
• Audiometric testing at least 6 weeks after initial diagnosis to assess hearing 1

Indications for Otolaryngology Referral

• Traumatic perforations associated with:
  • Vertigo
  • Significant hearing loss
• Perforations from acute otitis media that don't heal within one month
• Chronic perforations
• Suspected ossicular chain disruption or cholesteatoma
• Patients with comorbidities requiring more vigilant monitoring 1, 2

Surgical Management

• Consider tympanoplasty for perforations that fail to heal spontaneously
• Surgery should be considered particularly for perforations in contact with the malleus 5
• Long-term observation (≥6 months) may be appropriate when signs of spontaneous closure are observed 5

Common Pitfalls and Caveats

• Avoid ototoxic ear drops in patients with perforations
• Never irrigate an ear with a suspected or confirmed perforation
• Patients with perforations should be counseled about keeping the ear dry
• Most trials of otitis media have excluded children with Down syndrome and craniofacial malformations, so evidence in these populations is limited 7