What is the treatment for a perforated ear drum?

Treatment of Perforated Ear Drum

Most tympanic membrane perforations heal spontaneously within 2-3 weeks and require keeping the ear dry, avoiding water entry, and possibly using topical antibiotics if infection is present. 1

Initial Management

• Keep the ear dry:

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

• Medication for infected perforations:

  • For chronic suppurative otitis media with perforated tympanic membranes:
    • Adults and children ≥12 years: Ten drops (0.5 mL) of ofloxacin otic solution twice daily for fourteen days 2
    • Warm solution before instillation to prevent 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 2

Management Based on Perforation Type

Acute Perforations

1. Traumatic perforations:

   • Most heal spontaneously within 2-3 weeks 1, 3
   • Keep ear dry to prevent infection
   • Follow-up within 3 months to assess healing 1

2. Perforations from acute otitis media:

   • Treat with non-ototoxic topical antibiotics (fluoroquinolone drops) 1
   • Apply twice daily for up to 10 days
   • Pain management with acetaminophen or NSAIDs for mild to moderate pain 1
   • Re-evaluate within 48-72 hours if symptoms don't improve 1

Chronic Perforations

• Surgical intervention is typically required for:
  • Perforations that don't heal within 3 months 1, 4
  • Chronic perforations associated with recurrent infections 1
  • Perforations causing moderate to severe hearing loss 1
  • Tympanoplasty is recommended for persistent perforations with recurrent infections and moderate to severe mixed hearing loss 1

When to Refer to an Otolaryngologist

Referral is indicated for:

• Perforations that don't heal within 1-3 months 1, 4
• Traumatic perforations with vertigo or significant hearing loss 1, 4
• Suspected ossicular chain disruption 1, 4
• Presence of cholesteatoma 1, 5
• Patients with comorbidities (especially diabetes) 1
• Continuous pain, vertigo, or facial paralysis 3

Monitoring and Follow-up

• Most acute symptoms resolve within 48-72 hours with appropriate treatment 1
• Follow-up within 3 months to assess healing 1
• Audiometric testing should be performed at least 6 weeks after initial diagnosis 1

Important Precautions

• Avoid:
  • Irrigation and pneumatic otoscopy 4
  • Using potentially ototoxic drops containing aminoglycosides 1
  • Unnecessary systemic antibiotics 1

Prognosis

• Most small perforations heal spontaneously 4
• Healing rates are influenced by:
  • Size and location of perforation (smaller perforations heal faster) 1
  • Age (children, especially under 2, may take longer to clear effusions) 1
  • Presence of infection

Common Pitfalls to Avoid

1. Using ototoxic ear drops (containing aminoglycosides) which can cause permanent hearing loss 1
2. Prescribing systemic antibiotics when topical therapy is sufficient 1
3. Failing to keep the ear dry, which can lead to infection and delayed healing 1, 3
4. Missing unsafe perforations associated with cholesteatoma, which requires surgical intervention 5
5. Delaying referral for perforations with alarming signs (vertigo, facial paralysis, severe pain) 3, 4