What is the treatment for a left ear infection with a ruptured tympanic membrane (TM)?

Treatment for Left Ear Infection with Ruptured Tympanic Membrane

For a left ear infection with a ruptured tympanic membrane, a non-ototoxic topical antibiotic preparation should be prescribed to avoid potential hearing damage. 1

Initial Assessment and Management

1. Ear Canal Cleaning

   • Gently clean the ear canal of debris and discharge using atraumatic methods
   • Avoid irrigation with water as this can worsen the infection 1
   • Suction cleaning under microscopic guidance may be necessary in patients with risk factors (diabetes, immunocompromised state) 1

2. Topical Therapy Selection

   • Use only non-ototoxic preparations due to the perforated tympanic membrane
   • Avoid aminoglycoside-containing eardrops due to risk of ototoxicity 2
   • Suitable options include:
     • Fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) 2
     • For fungal infections (otomycosis), consider boric acid or acetic acid solutions 1

3. Wick Placement

   • Consider placing a wick if ear canal edema prevents drop entry or if most of the tympanic membrane cannot be visualized
   • Use compressed cellulose wicks (preferred) or ribbon gauze
   • Moisten the wick with an aqueous solution before first application of medication 1
   • Remove the wick once ear canal edema subsides (usually within 24 hours to a few days) 1

Systemic Antibiotic Therapy

1. When to Consider Systemic Antibiotics

   • For severe external auditory canal edema where adequate aural toilet or wick placement is not possible 1
   • For cases with signs of middle ear infection (acute otitis media)

2. Antibiotic Selection

   • For acute otitis media with perforation:
     • Amoxicillin-clavulanate is first-line therapy 2
     • For penicillin allergy: cefdinir, cefuroxime, or cefpodoxime 2
     • For severe penicillin allergy: clindamycin or ceftriaxone (if not allergic to cephalosporins) 2, 3

Duration of Treatment

• Limit topical therapy to a single course of no more than 10 days 2
• For systemic antibiotics:
  • 10-day course for severe symptoms
  • 7-day course for mild/moderate symptoms in patients 2-5 years
  • 10-day course for patients ≥6 years with mild/moderate symptoms 2

Patient Education and Follow-up

1. Keep the Ear Dry

   • Advise patient to avoid getting water in the ear until the perforation heals 4
   • Use ear plugs or cotton balls coated with petroleum jelly when showering

2. Follow-up Assessment

   • Evaluate response to therapy within 48-72 hours 2
   • If no improvement after 72 hours, consider switching to an alternative antibiotic or reevaluation 2
   • Monitor for common side effects of systemic antibiotics, including diarrhea 2

3. When to Refer to ENT

   • If perforation persists beyond one month 5
   • If there are alarming signs such as:
     • Continuous pain
     • Vertigo
     • Facial paralysis 4
   • If hearing loss is significant (>30 dB) 5

Special Considerations

1. For Chronic Suppurative Otitis Media

   • Consider broader spectrum coverage for Pseudomonas, Staphylococcus, and anaerobes like Bacteroides 6
   • Surgical intervention may be necessary for definitive treatment of chronic perforations 6

2. For Fungal Infections (Otomycosis)

   • Consider topical therapy with boric acid, acetic acid, or azole cream
   • For refractory cases with perforated tympanic membranes, oral antifungals like voriconazole, posaconazole, or itraconazole may be appropriate 1

By following this approach, you can effectively treat the ear infection while minimizing the risk of complications and promoting healing of the tympanic membrane perforation.