What is the management for a perforated eardrum?

Management of Perforated Eardrum

Most tympanic membrane perforations heal spontaneously within 2-3 weeks and should be managed conservatively by keeping the ear dry, using appropriate topical antibiotics for infected perforations, and providing adequate pain management. 1

Initial Assessment and Classification

• Determine the cause of perforation:

  • Traumatic (direct trauma, blast injury, barotrauma)
  • Infectious (acute otitis media)
  • Chronic (associated with chronic otitis media)

• Assess for concerning symptoms:

  • Vertigo or dizziness (may indicate inner ear involvement)
  • Significant hearing loss (>30 dB suggests ossicular chain disruption)
  • Facial paralysis (indicates potential complication)
  • Persistent pain (may indicate ongoing infection)
  • Nausea and vomiting (suggests inner ear involvement) 2

Management Algorithm

1. Acute Traumatic Perforations

• Keep the ear dry - advise patients to:

  • 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:

  • Acetaminophen or NSAIDs for mild to moderate pain
  • Consider stronger analgesics for severe pain 1

• Avoid:

  • Ear irrigation
  • Pneumatic otoscopy
  • Cotton-tip applicators for cleaning 2, 3

• Follow-up:

  • Re-evaluate within 3 months to assess healing
  • Most traumatic perforations heal spontaneously within 6-8 weeks 1, 4

2. Infectious Perforations (from Acute Otitis Media)

• Antibiotic therapy:

  • Non-ototoxic topical antibiotic preparations (fluoroquinolone drops) as first-line therapy
  • Apply twice daily for up to 10 days 1
  • Consider oral antibiotics for systemic symptoms

• Pain management as outlined above

• Keep the ear dry as outlined above

• Follow-up:

  • Re-evaluate within 48-72 hours if symptoms don't improve
  • Follow-up within 3 months to assess healing 1

3. Chronic Perforations

• Keep the ear dry to prevent infection
• Regular cleaning of the ear canal by a healthcare professional
• Surgical consultation for repair (tympanoplasty) as these typically do not heal spontaneously 5

Indications for ENT Referral

• Perforations that do not heal within 1 month (for acute perforations)
• Traumatic perforations with:
  • Vertigo
  • Significant hearing loss
  • Suspected ossicular chain disruption
• Chronic perforations
• Suspected cholesteatoma
• Continuous pain despite treatment
• Facial paralysis 1, 6, 2

Audiometric Assessment

• Perform audiometric testing at least 6 weeks after initial diagnosis to assess hearing 1
• Conductive hearing loss >30 dB suggests ossicular chain disruption 2

Special Considerations

• Children: All children in one study demonstrated complete spontaneous recovery from traumatic perforations 4

• Patients with diabetes: Higher risk of malignant otitis externa; should be monitored more closely and instructed to report development of otorrhea or otalgia promptly 7

• Swimmers: Should avoid swimming until the perforation has healed completely; those with chronic perforations should use waterproof earplugs 3

Potential Complications

• Hearing loss (usually conductive)
• Chronic suppurative otitis media
• Cholesteatoma formation
• Ototoxicity (if inappropriate drops are used) 1

Remember that most acute perforations heal spontaneously with conservative management, while chronic perforations often require surgical intervention for definitive treatment 6, 5.