What is the treatment for a ruptured tympanic membrane (eardrum)?

Treatment of Ruptured Tympanic Membrane

Most ruptured eardrums should be managed conservatively with watchful waiting, keeping the ear dry, and avoiding ear irrigation, as 95% of traumatic perforations heal spontaneously with proper care. 1, 2

Initial Management

Conservative Approach

• Keep the ear dry - patients should avoid water entry into the ear canal 1
• Use protection when showering - earplugs or petroleum jelly-coated cotton 1
• Avoid activities that create pressure changes 1:
  • Forceful nose blowing
  • Using straws for drinking
  • Air travel (if possible)
  • Vigorous exercise or heavy lifting

Medication Management

• Pain control: Acetaminophen or NSAIDs for mild to moderate pain; combination analgesics with opioids may be necessary for severe pain 1
• For infected perforations:
  • Topical non-ototoxic fluoroquinolone drops (e.g., ofloxacin 0.3%) are more effective than systemic antibiotics
  • Recommended dosage: ten drops (0.5 mL) twice daily for 14 days 1
  • If associated with acute otitis media, appropriate antibiotics are recommended 1
• AVOID ototoxic ear drops - can cause hearing loss and balance disturbance 1
• AVOID ear syringing/irrigation - can worsen perforation or cause infection 1

Special Situations

Fungal Infections (Otomycosis)

• Topical antifungal therapy such as clotrimazole solution is appropriate 1
• For refractory cases: voriconazole, posaconazole, or itraconazole may be used 1
• Avoid topical antibiotics as they may promote fungal overgrowth 1

High-Risk Patients

• Patients with diabetes, immunocompromised state, or history of radiotherapy:
  • More susceptible to otomycosis and necrotizing otitis externa
  • May require systemic antibiotics in addition to topical therapy 1
  • Require closer monitoring due to higher risk of malignant otitis externa 1

Follow-up and Monitoring

• Schedule follow-up within 3 months to assess healing 1
• Perform audiometric testing at least 6 weeks after initial diagnosis 1
• Monitor for signs of serious complications requiring immediate attention 1:
  • Increasing pain
  • Fever
  • Spreading redness
  • Facial weakness

When to Refer to an Otolaryngologist

Referral is recommended in the following situations 1:

• Perforation fails to heal after 3 months of observation
• Significant hearing loss (>30 dB conductive loss) is present
• Persistent tinnitus that is bothersome to the patient
• Alarming signs such as continuous pain, vertigo, or facial paralysis 3
• Blast injury (risk of secondary cholesteatoma) 2

Surgical Management

Tympanoplasty is recommended for 1:

• Persistent tympanic membrane perforation
• Recurrent ear infections
• Moderate to severe mixed hearing loss

Prognosis

• 95% of traumatic perforations heal spontaneously with proper care 2
• Children demonstrate complete spontaneous recovery in most cases 4
• Middle ear effusion resolution rates 1:
  • 2 weeks: 30-40%
  • 1 month: 60-70%
  • 3 months: 75-90%

Common Pitfalls to Avoid

• Using ototoxic ear drops in patients with perforated eardrums
• Performing ear irrigation/syringing with a perforated eardrum
• Failing to recognize signs of serious complications requiring immediate attention
• Neglecting follow-up for persistent perforations (>3 months)
• Overlooking the need for hearing assessment with persistent perforations