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

Treatment for Tympanic Membrane Perforation

Most tympanic membrane perforations heal spontaneously with conservative management, requiring only watchful waiting, keeping the ear dry, and appropriate follow-up. 1, 2

Initial Management

Assessment and Classification

• Determine cause of perforation:
  • Trauma (blunt or penetrating)
  • Acute otitis media
  • Chronic middle ear infection
• Evaluate size and location of perforation
• Check for signs requiring urgent ENT referral:
  • Continuous pain
  • Vertigo
  • Facial paralysis
  • Significant hearing loss (>30 dB)

Conservative Management (First-Line)

1. Keep the ear dry 2

   • Avoid swimming until cleared by physician
   • Use earplugs or petroleum jelly-coated cotton when showering 3
   • Avoid activities that create pressure changes

2. Watchful waiting 1

   • 95% of traumatic perforations heal spontaneously with this approach
   • All children demonstrate complete spontaneous recovery 4

3. Pain management 3

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

Infection Management

• For perforations caused by acute otitis media:

  • Oral antibiotics are recommended 2, 5
  • First choice: Amoxicillin
  • Second choice: Amoxicillin-clavulanate 3

• For infected perforations:

  • Topical non-ototoxic fluoroquinolone drops (ofloxacin 0.3%) are more effective than systemic antibiotics
  • Recommended dosage: Ten drops (0.5 mL) twice daily for 14 days 3

• For fungal infections:

  • Topical therapy with irrigating solutions of boric acid, acetic acid, or azole cream 3
  • Oral antifungals (voriconazole, posaconazole, or itraconazole) for refractory cases 3

Follow-Up and Monitoring

Expected Healing Timeline

• Middle ear effusion resolution rates:
  • 2 weeks: 30-40%
  • 1 month: 60-70%
  • 3 months: 75-90% 3

When to Refer to ENT

• Perforation failing to heal after 3 months
• Significant hearing loss (>30 dB conductive loss)
• Persistent vertigo
• Facial nerve weakness
• Suspected cholesteatoma formation 3, 5
• Blast injuries (higher risk of secondary cholesteatoma) 1

Surgical Management (Second-Line)

Indications for Surgical Intervention

• Chronic perforation that doesn't heal spontaneously
• Perforations due to chronic middle ear infection or cholesteatoma 2
• Significant hearing loss due to the perforation

Surgical Options

• Tympanoplasty for persistent perforations 4
• Success rates are high, with most patients achieving complete closure 4

Special Considerations

Population-Specific Management

• Children: Take longer to clear effusions, especially those under 2 years 3
• Diabetic patients: Require closer monitoring due to higher risk of malignant otitis externa 3
• Immunocompromised patients: More susceptible to otomycosis and necrotizing otitis externa 3
• Elderly patients: Should be vigilant for necrotizing otitis externa 3

Important Precautions

• Avoid irrigation of the ear canal 5
• Avoid pneumatic otoscopy 5
• Carefully suction blood, purulent secretions, and debris from the ear canal 5

Potential Complications

• Conductive hearing loss (1.8-11% of cases) 3
• Persistent tympanic membrane perforation (1-4.2% of cases) 3
• Ossicular chain disruption (3.6% of cases) 3
• Recurrent middle ear infections 2

The high rate of spontaneous healing (95% for traumatic perforations) supports a conservative approach as first-line management for most tympanic membrane perforations 1. Surgical intervention should be reserved for perforations that fail to heal after 3 months or those associated with chronic middle ear disease.