What to do with a ruptured eardrum (tympanic membrane perforation)?

Management of Tympanic Membrane Perforation

For a ruptured eardrum (tympanic membrane perforation), the recommended approach is watchful waiting with appropriate precautions to keep the ear dry, as most traumatic perforations heal spontaneously within 3 months without surgical intervention. 1

Initial Assessment and Management

• Keep the ear dry: This is crucial to prevent infection while the perforation heals

  • Use earplugs or petroleum jelly-coated cotton when showering 2
  • Avoid swimming until cleared by a physician 2
  • Avoid activities that create pressure changes in the ear 2

• Avoid inserting anything into the ear canal including cotton swabs or other objects

• Pain management:

  • Mild to moderate pain: Acetaminophen or NSAIDs
  • Severe pain: May require combination analgesics with opioids 2

Infection Management

If signs of infection develop (discharge, increasing pain, fever):

• Use topical non-ototoxic antibiotic drops:

  • Ofloxacin 0.3% is recommended for perforated eardrums 3
  • Dosage for patients 12 years and older: Ten drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 3
  • For children 1-12 years: Five drops (0.25 mL) twice daily for ten days 3

• Administration technique:

  1. Warm the solution by holding the bottle in hand for 1-2 minutes
  2. Lie with the affected ear upward
  3. Instill drops into ear canal
  4. Pump the tragus 4 times to facilitate penetration into the middle ear
  5. Maintain position for five minutes 3

Follow-up and Monitoring

• Regular follow-up to monitor healing progress
• Most traumatic perforations (95%) heal completely with watchful waiting 1
• If perforation fails to heal after 3 months, referral to an otolaryngologist is recommended 2, 4

When to Seek Specialist Care

Immediate ENT consultation is needed if:

• Continuous pain persists
• Vertigo occurs
• Facial paralysis develops
• Significant hearing loss (>30 dB conductive loss) is present
• Perforation persists beyond 3 months 2, 4

Special Considerations

• Blast injuries: These are an exception to watchful waiting and may require surgical exploration due to risk of secondary cholesteatoma 1

• Diabetic or immunocompromised patients: Require closer monitoring due to higher risk of malignant otitis externa 2

• Children: May take longer to clear associated middle ear effusions 2

The high spontaneous healing rate (95%) for traumatic perforations supports a conservative approach in most cases 1. While surgical options like tympanoplasty exist for persistent perforations, they are typically reserved for cases that don't heal after the observation period.