Management of Tympanic Membrane Perforation
For tympanic membrane perforations, the management approach depends on the cause, with most small traumatic perforations healing spontaneously with conservative care, while chronic perforations may require surgical intervention if they persist beyond 3 months. 1, 2, 3
Initial Assessment and Management
Traumatic Perforations
- Keep the ear dry to prevent infection
- Avoid irrigation and pneumatic otoscopy
- Most heal spontaneously within 6-8 weeks 2, 4
- Carefully suction blood or debris from the ear canal
Infection-Related Perforations
- For perforations with active infection:
- Chronic suppurative otitis media with perforation: Ten drops (0.5 mL) of ofloxacin 0.3% instilled into the affected ear twice daily for fourteen days 5
- Position patient with affected ear upward during instillation
- Pump the tragus 4 times to facilitate penetration into the middle ear
- Maintain position for five minutes after instillation
Follow-up and Monitoring
- Initial follow-up within 3 months of injury/identification
- Audiometric testing recommended at least 6 weeks post-injury to assess hearing loss
- Patient education:
- Keep ear dry (avoid swimming until cleared by physician)
- Avoid activities creating pressure changes
- Use earplugs or petroleum jelly-coated cotton when showering 1
Indications for Otolaryngology Referral
Refer to an otolaryngologist if:
- Perforation fails to heal after 3 months of observation
- Significant hearing loss (>30 dB conductive loss) is present
- Patient experiences vertigo, nausea, or vomiting (suggesting ossicular chain disruption)
- Continuous pain persists
- Facial paralysis develops
- Signs of cholesteatoma are present 1, 2, 3
Special Considerations
Hearing Loss Assessment
- Conductive hearing loss >30 dB suggests ossicular chain disruption rather than simple perforation
- Profound sensorineural loss may indicate inner ear or nerve damage requiring urgent evaluation 2
Chronic Perforations
- Chronic perforations due to chronic otitis media or cholesteatoma typically require surgical intervention (tympanoplasty)
- Success rates for tympanoplasty are high, but complications can occur in up to 16% of patients within 4 weeks of surgery 1, 3
Pediatric Patients
- Children show excellent spontaneous healing rates for traumatic perforations 4
- Children may take longer to clear associated middle ear effusions 1
Pitfalls and Caveats
- Never irrigate a perforated eardrum - this can introduce infection into the middle ear
- Avoid ototoxic topical antibiotics (such as aminoglycosides) in patients with perforations
- Be vigilant for squamous epithelial growth through persistent perforations, especially those secondary to ventilation tubes, which requires surgical management 6
- Patients with diabetes or immunocompromised status require closer monitoring due to higher risk of malignant/necrotizing otitis externa 1