What is the treatment for a traumatic ruptured tympanic membrane (TM) in a 16-year-old?

Management of Traumatic Ruptured Tympanic Membrane in a 16-Year-Old

Most traumatic tympanic membrane perforations heal spontaneously and should be managed conservatively with observation, keeping the ear dry, and preventing infection.

Initial Assessment and Management

Evaluation

• Carefully assess the perforation size and location
• Gently suction blood, purulent secretions, and debris from the ear canal 1
• Avoid irrigation and pneumatic otoscopy as these can worsen the injury 1
• Document hearing status (conductive hearing loss >30 dB or profound sensorineural loss may indicate additional damage) 1

First-Line Treatment

1. Conservative management:

   • Allow for spontaneous healing (occurs in approximately 94% of cases) 2
   • Keep the ear dry to prevent infection 3
   • Avoid inserting anything into the ear canal, including cotton-tipped swabs 4
   • Cover the ear canal opening with an earplug or cotton with petroleum jelly before showering 5

2. Infection prevention:

   • For clean perforations without signs of infection, observation alone is appropriate
   • For perforations with discharge or signs of infection, use ofloxacin otic solution:
     • 10 drops (0.5 mL) twice daily for 14 days 5
     • Patient should lie with affected ear upward for 3-5 minutes after administration
     • Pump the tragus 4 times to facilitate drug penetration 5

Special Considerations

Medication Selection

• Preferred agent: Ofloxacin otic solution (non-ototoxic, safe for perforated TM) 5
• Alternative agents: Ciprofloxacin/dexamethasone (Ciprodex) or ciprofloxacin/hydrocortisone (Cipro HC) 5
• Avoid: Aminoglycoside-containing drops (e.g., neomycin) due to potential ototoxicity 5

Factors That May Delay Healing

• Large perforations (≥50% of TM)
• Ear discharge/infection
• Penetrating injuries through the ear canal
• Inappropriate interventions (e.g., ear syringing) 2
• Age (healing inversely related to patient age) 2

Follow-up and Referral

Follow-up Schedule

• Re-evaluate in 2-4 weeks to assess healing
• Most perforations heal within 4-8 weeks 2
• Complete the full 14-day course of antibiotics if prescribed, even if symptoms improve earlier 5

Indications for Otolaryngology Referral

• Persistent perforation beyond 4-8 weeks
• Significant hearing loss or vertigo (suggests ossicular chain disruption)
• Facial paralysis or other neurological symptoms
• Persistent drainage despite appropriate treatment
• Suspicion of cholesteatoma or chronic infection 3, 1

Patient Education

• Swimming should be avoided until the perforation heals 5
• Avoid getting water in the ear during bathing
• Avoid forceful nose blowing, which can force bacteria into the middle ear
• Return for evaluation if experiencing increased pain, drainage, hearing loss, or dizziness

Surgical Management

• Surgical intervention (tympanoplasty) is rarely needed for traumatic perforations in adolescents
• Consider only if perforation fails to heal spontaneously after 3 months of observation 6
• All children in the reviewed studies demonstrated complete spontaneous recovery 6

The high rate of spontaneous healing (94%) in traumatic perforations, especially in younger patients, supports a conservative approach with careful monitoring as the most appropriate initial management strategy for this 16-year-old patient.