What is the treatment for a perforated eardrum?

Management of Perforated Tympanic Membrane

Most perforated eardrums heal spontaneously within 2-3 weeks with proper care and protection from infection, though complete resolution of middle ear effusion may take up to 3 months in some cases. 1

Initial Assessment and Management

• Diagnosis: Evaluate the perforation size, location, and cause (trauma, acute infection, or chronic infection)
• Symptoms: Typically include mild conductive hearing loss, aural fullness, and mild tinnitus 2
• Warning signs requiring immediate ENT referral:
  • Continuous pain
  • Vertigo or dizziness (suggests possible ossicular chain disruption)
  • Facial paralysis
  • Profound hearing loss (>30 dB conductive loss)
  • Signs of infection extending beyond the ear canal 1, 2

Treatment Approach

1. Keep the Ear Dry

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

2. Prevent Pressure Changes

• Avoid:
  • Nose blowing
  • Using straws for drinking
  • Air travel
  • Vigorous exercise or heavy lifting
• When sneezing, do so with mouth open 1

3. Medication Management

For Clean Perforations (Traumatic)

• Most heal spontaneously without antibiotics 3
• Pain management with acetaminophen or NSAIDs for mild to moderate pain 1

For Infected Perforations

• Topical treatment: Non-ototoxic fluoroquinolone drops (e.g., ofloxacin 0.3%)
  • Dosage: Ten drops (0.5 mL) twice daily for 14 days 1
  • Topical quinolones are more effective than systemic antibiotics for clearing discharge 4
• Systemic antibiotics: Only if infection extends beyond ear canal or in patients with specific risk factors 1

4. Avoid Harmful Practices

• Do not irrigate the ear
• Do not perform pneumatic otoscopy
• Do not use ear candles 5, 2
• Do not use potentially ototoxic drops (can damage hearing) 1

Follow-up and Referral

Follow-up Timeline

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

Indications for ENT Referral

• Perforation fails to heal after 3 months
• Significant hearing loss (>30 dB conductive loss)
• Persistent symptoms despite treatment
• Chronic suppurative otitis media
• Suspected cholesteatoma 1, 2

Prognosis and Healing Rates

• Small traumatic perforations: Excellent prognosis with spontaneous healing in most cases 3
• Healing rates for middle ear effusion:
  • 2 weeks: 30-40%
  • 1 month: 60-70%
  • 3 months: 75-90% 1
• Children typically show complete spontaneous recovery 3
• Factors affecting healing:
  • Size and location of perforation (smaller perforations heal faster)
  • Cause of perforation (traumatic better than chronic infection)
  • Patient age (children heal better than adults) 1, 3

Surgical Options

• Tympanoplasty indicated for:
  • Persistent perforations after 3 months
  • Recurrent ear infections
  • Moderate to severe mixed hearing loss 1
• Success rates for tympanoplasty are high, with most patients achieving complete closure and hearing improvement 3

Special Considerations

• Diabetic patients: Higher risk of malignant otitis externa; require closer monitoring 1
• Children under 2: May take longer to clear effusions 1
• Chronic perforations: Usually require surgical intervention, especially if associated with chronic middle ear infection or cholesteatoma 6