Treatment of Perforated Tympanic Membrane
For perforated tympanic membranes, non-ototoxic topical fluoroquinolone drops (such as ofloxacin) are the recommended first-line treatment, with most small perforations healing spontaneously within 2-3 weeks with appropriate care. 1
Initial Management
Assessment
- Determine cause of perforation (trauma, acute otitis media, chronic infection)
- Assess for pain and provide appropriate analgesia 1
- Evaluate for factors that may complicate management:
- Size and location of perforation
- Presence of infection
- Hearing loss severity
- Vertigo (suggests possible ossicular chain disruption) 2
Immediate Care
- Carefully suction blood, purulent secretions, and debris from ear canal 2
- Avoid irrigation and pneumatic otoscopy as these can worsen the perforation or introduce infection 2
- Keep the ear dry by:
- Avoiding water entry
- Using earplugs or petroleum jelly-coated cotton when showering
- Avoiding swimming until cleared by physician 1
Medical Treatment
Topical Therapy
- For perforated tympanic membranes, use non-ototoxic topical preparations 3, 1
- Fluoroquinolone drops (e.g., ofloxacin 0.3%) are recommended as they:
- Are effective against common ear pathogens
- Have no ototoxicity (unlike aminoglycoside-containing preparations)
- Are specifically approved for use with non-intact tympanic membranes 4
Dosing for Ofloxacin Otic Solution 0.3%
- For chronic suppurative otitis media with perforated tympanic membranes (patients ≥12 years):
- Ten drops (0.5 mL) instilled into affected ear twice daily for fourteen days 5
- Application technique:
- Warm solution by holding bottle in hand for 1-2 minutes
- Patient should lie with affected ear upward
- Pump tragus 4 times to facilitate penetration into middle ear
- Maintain position for five minutes 5
Pain Management
- Assess pain severity and recommend appropriate analgesics:
- Mild to moderate pain: acetaminophen or NSAIDs
- Severe pain: combination analgesics with opioids may be considered 1
Systemic Antibiotics
- Systemic antibiotics should not be routinely prescribed unless there is:
Follow-up and Monitoring
Expected Healing Timeline
- Most small perforations heal spontaneously within 2-3 weeks 1, 2
- Complete resolution of middle ear effusion may take up to 3 months 1
- Effusion resolution rates:
- 2 weeks: 30-40%
- 1 month: 60-70%
- 3 months: 75-90% 1
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
Referral to Otolaryngologist
Indications for Referral
- Perforation fails to heal after 3 months of observation
- Significant hearing loss (>30 dB conductive loss)
- Traumatic perforations with vertigo
- Suspected ossicular chain disruption
- Presence of cholesteatoma
- Recurrent ear infections with persistent perforation 1, 2
Surgical Management
- Tympanoplasty may be recommended for:
- Persistent tympanic membrane perforation
- Recurrent ear infections
- Moderate to severe mixed hearing loss 1
Special Considerations
Cautions
- Never use potentially ototoxic drops (containing aminoglycosides) as they can cause permanent hearing loss 1
- Patients with diabetes require closer monitoring due to higher risk of malignant otitis externa 1
- Children may take longer to clear effusions 1
Treatment Efficacy
- Ofloxacin otic solution has demonstrated clinical cure rates of 75-91% in chronic suppurative otitis media with perforated tympanic membranes 4
- In traumatic perforations, ofloxacin otic solution showed a 97.6% closure rate compared to 79.2% with spontaneous healing 6
- Ciprofloxacin/dexamethasone combinations should be avoided as the steroid component may delay healing of tympanic membrane perforations 7
Complications
- Potential complications of untreated or improperly treated perforations include:
- Hearing loss
- Chronic suppurative otitis media
- Cholesteatoma formation
- Ototoxicity if inappropriate drops are used 1