What is the treatment for a ruptured tympanic membrane?

Treatment of Ruptured Tympanic Membrane

For ruptured tympanic membrane, topical non-ototoxic fluoroquinolone antibiotic drops (e.g., ofloxacin) are recommended as first-line therapy, applied twice daily for up to 10 days, while keeping the ear dry and allowing most perforations to heal spontaneously within 2-3 weeks. 1

Initial Assessment and Management

1. Pain Management:

   • Assess pain level and provide appropriate analgesia
   • Mild to moderate pain: Acetaminophen or NSAIDs
   • Severe pain: Combination analgesics with opioids 1

2. Antibiotic Therapy:

   • Topical antibiotics are more effective than systemic antibiotics
   • Use non-ototoxic fluoroquinolone drops (e.g., ofloxacin) twice daily for up to 10 days 1
   • Avoid potentially ototoxic drops containing aminoglycosides as they can cause permanent hearing loss 1
   • Systemic antibiotics are not recommended unless infection extends beyond the ear canal 1

3. Keep the Ear Dry:

   • Avoid water entry into the ear
   • Use earplugs or petroleum jelly-coated cotton when showering
   • No swimming until cleared by physician 1

Management Based on Etiology

Traumatic Perforations

• Most heal spontaneously without intervention 2, 3
• Keep ear dry and clean
• All pediatric cases typically demonstrate complete spontaneous recovery 3
• Avoid irrigation and pneumatic otoscopy 4

Infection-Related Perforations

• Treat underlying acute otitis media with appropriate antibiotics
• Carefully suction blood, purulent secretions, and debris from the ear canal 4
• Monitor for resolution of middle ear effusion (may take up to 3 months in some cases) 1

Follow-Up and Monitoring

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

Expected Healing Timeline

• Most small perforations heal spontaneously within 2-3 weeks 1
• Middle ear effusion resolution rates:
  • 2 weeks: 30-40%
  • 1 month: 60-70%
  • 3 months: 75-90% 1

Referral to Otolaryngologist

Refer to an ENT specialist if:

• Perforation fails to heal after 3 months of observation 1, 2
• Significant hearing loss (>30 dB conductive loss) is present 1, 4
• Patient experiences vertigo, nausea, or vomiting (suggesting ossicular chain disruption) 4
• Facial paralysis or continuous pain occurs 2
• Chronic perforation due to chronic otitis media or cholesteatoma is present 2

Surgical Management

Consider tympanoplasty for:

• Persistent tympanic membrane perforation
• Recurrent ear infections
• Moderate to severe mixed hearing loss 1

Special Considerations

• Diabetic patients: Higher risk of malignant otitis externa; monitor more closely 1
• Children under 2: May take longer to clear effusions 1
• Size and location of perforation: Smaller perforations heal faster than larger ones 1

Complications to Monitor

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

Tinnitus Management (if persistent)

• Education and counseling about management strategies
• Sound therapy may be beneficial
• Hearing aid evaluation for patients with hearing loss
• Cognitive-behavioral therapy (CBT) is strongly recommended 1
• Avoid routine use of antidepressants, anticonvulsants, anxiolytics, or intratympanic medications 1