What to do for a 5-year-old with a perforated (tympanic membrane) eardrum?

Management of Eardrum Perforation in a 5-Year-Old Child

For a 5-year-old child with a perforated eardrum, watchful waiting for 3 months is the recommended first-line approach, as most traumatic perforations heal spontaneously without intervention. 1, 2

Initial Assessment and Management

1. Determine cause of perforation:

   • Trauma (slap, foreign body, barotrauma)
   • Acute otitis media
   • Chronic infection

2. Immediate care:

   • Keep the ear dry - avoid water entry into the ear canal 3
   • Avoid ear canal irrigation 3
   • Carefully suction any blood, purulent secretions, or debris from the ear canal 4
   • Document size and location of perforation 4
   • Do not perform pneumatic otoscopy on a perforated eardrum 4

3. Pain management:

   • Acetaminophen or NSAIDs for mild to moderate pain 3
   • More potent analgesics may be needed for severe pain 3

Treatment Based on Cause

For traumatic perforation:

• Watchful waiting is appropriate with otolaryngologic follow-up 1
• 95-99% of traumatic perforations heal spontaneously 1, 2
• All children in studies demonstrated complete spontaneous recovery 2

For infection-related perforation:

• If associated with acute otitis media, treat with appropriate antibiotics 5
• For external ear infections with perforated membrane:
  • Use ofloxacin 0.3% otic solution (10 drops twice daily for 14 days) 3
  • Avoid ototoxic topical preparations to prevent hearing loss 3

Follow-up and Monitoring

1. Schedule follow-up within 3 months to assess healing 3

2. Obtain age-appropriate hearing test if:

   • Perforation persists for ≥3 months 6
   • Child shows signs of hearing difficulties, balance problems, or speech/language concerns 6

3. Monitor for complications:

   • Increasing pain, fever, spreading redness (signs of infection) 3
   • Persistent hearing loss
   • Vertigo (may indicate ossicular chain disruption) 4

When to Refer to an Otolaryngologist

Immediate referral if:

• Continuous pain, vertigo, or facial paralysis 5
• Significant hearing loss (>30 dB conductive loss) 3, 4

Delayed referral if:

• Perforation fails to heal after 3 months of observation 3, 5
• Chronic perforation develops 5

Surgical Considerations

• For children <4 years old with persistent middle ear effusion requiring surgery, tympanostomy tubes are recommended without adenoidectomy 6
• For children ≥4 years old with persistent middle ear effusion requiring surgery, tympanostomy tubes, adenoidectomy, or both may be recommended 6
• Tympanoplasty may be considered for persistent perforations that don't heal after 3 months 3

Patient/Parent Education

1. Explain natural history:

   • Most perforations heal spontaneously within 3 months 1, 2
   • Middle ear effusion resolution rates: 30-40% at 2 weeks, 60-70% at 1 month, 75-90% at 3 months 3

2. Preventive measures:

   • Keep ear dry; use earplugs or petroleum jelly-coated cotton when bathing 3
   • Avoid swimming until cleared by physician 3
   • Avoid activities creating pressure changes (forceful nose blowing, using straws, air travel if possible) 3

3. Warning signs requiring immediate attention:

   • Increasing pain, fever, spreading redness, facial weakness 3
   • Persistent or worsening hearing loss
   • Persistent drainage from ear

Important Cautions

• Never use ear drops containing potentially ototoxic agents in a perforated eardrum 3
• Avoid ear canal irrigation with a perforated eardrum 3
• Do not perform pneumatic otoscopy on a perforated eardrum 4

Following this approach will maximize the chances of spontaneous healing while minimizing complications and preserving hearing in the 5-year-old child with a perforated eardrum.