What is the treatment for tympanic membrane (TM) perforation?

Treatment of Tympanic Membrane Perforation

For tympanic membrane (TM) perforations, the recommended treatment includes keeping the ear dry, using non-ototoxic topical antibiotics like ofloxacin 0.3% otic solution for infected perforations, and allowing most small perforations to heal spontaneously while referring persistent perforations for surgical repair. 1

Initial Management

Assessment and Protection

• Keep the affected ear dry
• Avoid water entry into the ear canal
• Use earplugs or petroleum jelly-coated cotton when showering
• Avoid swimming until cleared by a physician 1
• Avoid activities creating pressure changes:
  • Forceful nose blowing
  • Using straws for drinking
  • Air travel if possible
  • Vigorous exercise or heavy lifting 1

Medication Management

• For infected perforations or discharge:
  • Use non-ototoxic topical preparations such as ofloxacin 0.3% otic solution 1
  • Dosage for patients 12 years and older: Ten drops (0.5 mL) twice daily for fourteen days 2
  • Dosage for pediatric patients (1-12 years) with tympanostomy tubes: Five drops (0.25 mL) twice daily for ten days 2
• Pain management:
  • Acetaminophen or NSAIDs for mild to moderate pain
  • Consider fixed interval dosing rather than as-needed for better pain control 1

Treatment Based on Perforation Type

Traumatic Perforations

• Most small traumatic perforations (especially in children) heal spontaneously within 1-3 months 3
• Ofloxacin ear drops significantly improve healing outcomes:
  • Increase closure rate (97.6% vs 79.2% for spontaneous healing)
  • Reduce healing time (13.12 days vs 49.51 days for spontaneous healing) 4
• Recent meta-analysis confirms ofloxacin reduces healing time and increases closure rates without increasing risk of hearing loss or infection 5

Chronic Suppurative Otitis Media with Perforation

• Topical antibiotics are more effective than systemic antibiotics for clearing discharge 1
• Systemic antibiotics should not be routinely prescribed unless there is extension of infection beyond the ear canal 1

Advanced Treatment Options

For Persistent Perforations

• Gelfoam patching may be effective for large perforations with 87.2% closure rate 4
• Combined approaches using ofloxacin, basic fibroblast growth factor, or Gelfoam patching all accelerate closure of moderate to large traumatic perforations 6
• Tympanoplasty is recommended for:
  • Perforations that fail to heal after 3 months of observation
  • Recurrent ear infections
  • Moderate to severe mixed hearing loss 1

Follow-up and Monitoring

• Schedule follow-up within 3 months to assess healing
• Perform audiometric testing at least 6 weeks after initial diagnosis 1
• Watch for signs of worsening infection:
  • Increasing pain
  • Fever
  • Spreading redness
  • Facial weakness 1
• Referral to an otolaryngologist if:
  • Perforation fails to heal after 3 months
  • Significant hearing loss (>30 dB conductive loss) is present
  • Vertigo, nausea, or vomiting occurs (suggesting ossicular chain disruption) 1, 7

Special Considerations

• Elderly patients should be monitored for necrotizing (malignant) otitis externa
• Patients with diabetes are at higher risk of malignant otitis externa 1
• Children typically have better spontaneous healing rates than adults 3
• Avoid irrigation and pneumatic otoscopy in patients with TM perforations 7

Potential Complications

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