What is the treatment for a perforated eardrum?

Treatment for a Perforated Eardrum

Most perforated eardrums heal spontaneously within 6-12 weeks and require conservative management including keeping the ear dry, avoiding water exposure, and monitoring for complications. 1, 2, 3

Initial Management Based on Cause

Traumatic Perforation

• Keep the ear dry and clean
• Avoid water exposure (use earplugs or petroleum jelly-coated cotton when showering) 4
• Avoid activities that create pressure changes 4
• Monitor for spontaneous healing (occurs in most cases) 2, 3
• No antibiotics needed unless signs of infection develop

Infection-Related Perforation

• For acute otitis media with perforation:
  • Initial observation without antibiotics in uncomplicated cases 5
  • If antibiotics needed: Amoxicillin is first-line treatment 5
  • For perforations with evidence of pus: Consider targeted antibiotics based on likely pathogens (staphylococci, pseudomonas, pneumococci) 5
• For otomycosis (fungal infection) with perforation:
  • Topical antifungal treatment (e.g., Castellani's solution) 6
  • Consider paper patch technique to prevent fungi from passing to middle ear 6

Follow-up and Monitoring

• Initial follow-up within 3 months of injury/diagnosis 4
• Audiometric testing recommended at least 6 weeks after perforation 4
• Regular monitoring until healing occurs or complications resolve 4

When to Refer to an Otolaryngologist

Referral is indicated if:

• Perforation fails to heal after 3 months of observation 4, 1
• Significant hearing loss (>30 dB conductive loss) is present 4
• Alarming signs develop: continuous pain, vertigo, facial paralysis 1
• Infection doesn't respond to initial treatment within 48-72 hours 4
• Suspected cholesteatoma formation 4, 3

Surgical Management

• Tympanoplasty may be considered for:
  • Perforations that fail to heal spontaneously after 3 months 4, 3
  • Large perforations or those with significant hearing loss 4
  • Chronic perforations associated with cholesteatoma (unsafe perforations) 3

Common Pitfalls and Caveats

• Don't confuse otitis media with perforated eardrum with external otitis - proper diagnosis is essential for appropriate treatment 5
• Avoid ototoxic drops in patients with perforations as they can damage inner ear structures
• Children have higher rates of spontaneous healing (100% in one study) and may require less aggressive intervention 2
• Chronic perforations should be categorized as "safe" or "unsafe" based on risk of progression to complications; unsafe perforations (often associated with cholesteatoma) typically require surgical intervention 3
• Keeping the ear dry is crucial to prevent secondary infections and promote healing 1, 4