What is the treatment for ear perforation?

Treatment of Ear Perforation

The treatment for ear perforation includes keeping the ear dry, using topical non-ototoxic fluoroquinolone drops such as ofloxacin 0.3% (ten drops twice daily for fourteen days), avoiding activities that create pressure changes, and allowing most perforations to heal spontaneously within 2-3 weeks. 1

Initial Assessment and Management

• Diagnosis and Evaluation:

  • Determine cause of perforation (trauma, infection, etc.)
  • Assess size and location of perforation
  • Evaluate for presence of infection, hearing loss, and vertigo
  • Perform comprehensive audiologic examination 1

• Immediate Care:

  • Clean ear canal by carefully suctioning blood, purulent secretions, and debris
  • Avoid irrigation and pneumatic otoscopy as these can worsen the perforation 1, 2
  • Keep the ear dry to prevent infection 1, 3

Treatment Protocol

For Infected Perforations

1. Topical Antibiotics:

   • Use non-ototoxic fluoroquinolone drops (ofloxacin 0.3%)
   • Dosage: Ten drops (0.5 mL) twice daily for fourteen days for patients 12 years and older 1, 4
   • For children (1-12 years): Five drops twice daily for ten days 4
   • Warm the solution before instillation to prevent dizziness 4

2. Administration Technique:

   • Patient should lie with affected ear upward
   • Pump the tragus 4 times to facilitate penetration into the middle ear
   • Maintain position for five minutes 4

3. Systemic Antibiotics:

   • Not routinely recommended unless infection extends beyond ear canal
   • May be necessary for perforations related to acute otitis media 1, 2

Pain Management

• Assess pain level and provide appropriate analgesia
• Use acetaminophen or NSAIDs for mild to moderate pain
• Consider combination analgesics with opioids for severe pain 1

Patient Instructions

• Keep ear dry:

  • Use earplugs or petroleum jelly-coated cotton when showering
  • Avoid swimming until cleared by physician 1

• Avoid activities that create pressure changes:

  • No nose blowing
  • No using straws for drinking
  • Avoid air travel
  • Avoid vigorous exercise or heavy lifting
  • When sneezing, do so with mouth open 1

Follow-up and Monitoring

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

Prognosis and Healing

• Most traumatic perforations heal spontaneously (94% in one study) 5
• Small perforations heal faster than larger ones 1, 5
• Factors that delay healing:
  • Large perforations (≥50% of tympanic membrane)
  • Ear discharge/infection
  • Inappropriate interventions (e.g., ear syringing)
  • Penetrating injuries through ear canal 5

Referral to Otolaryngologist

Refer to specialist if:

• Perforation fails to heal after 3 months
• Significant hearing loss (>30 dB conductive loss) is present
• Patient experiences vertigo, continuous pain, or facial paralysis
• Chronic perforation due to chronic otitis media or cholesteatoma 1, 3, 2

Surgical Options

• Tympanoplasty is recommended 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
• Persistent tinnitus: May require additional management including sound therapy, hearing aid evaluation, or cognitive-behavioral therapy 1

Potential Complications of Untreated Perforations

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