What is the treatment for a perforated eardrum?

Treatment for Perforated Eardrum

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

Initial Management

• Keep the ear dry: Patients should avoid swimming and use earplugs or petroleum jelly-coated cotton when showering 1
• Avoid pressure changes: Activities that create pressure changes in the ear should be avoided 1
• Careful cleaning: Blood, purulent secretions, and debris should be carefully suctioned out of the canal 3
• Avoid irrigation and pneumatic otoscopy: These can worsen the perforation or introduce infection 3

Medication Management

For Infection-Related Perforations

• Topical therapy: Topical non-ototoxic fluoroquinolone drops (ofloxacin 0.3%) are more effective than systemic antibiotics, with a recommended dosage of ten drops twice daily for 14 days 1
• Systemic antibiotics: If systemic involvement exists:
  • First choice: Amoxicillin
  • Second choice: Amoxicillin-clavulanate 1, 4

For Fungal Infections

• Topical therapy with irrigating solutions of boric acid, acetic acid, or azole cream 1
• For refractory cases: Oral antifungals such as voriconazole, posaconazole, or itraconazole 1

Pain Management

• Mild to moderate pain: Acetaminophen or NSAIDs
• Severe pain: Combination analgesics with opioids 1

Follow-Up and Monitoring

• Initial follow-up within 3 months of perforation 1
• Audiometric testing at least 6 weeks after perforation to assess hearing status 1
• Regular follow-up until the perforation heals or complications resolve 1

Indications for ENT Referral

Refer to an otolaryngologist when:

• Perforation persists beyond 1 month 2, 3
• Alarming signs are present:
  • Continuous pain
  • Vertigo or dizziness
  • Facial paralysis
  • Significant hearing loss (>30 dB conductive loss)
  • Suspected cholesteatoma formation 1, 2, 3

Surgical Management

Surgical intervention (tympanoplasty) is indicated for:

• Chronic perforations that fail to heal after 3 months
• Perforations due to chronic middle ear infection or cholesteatoma
• Significant hearing loss associated with the perforation 1, 2, 3

Special Considerations

• Traumatic perforations: Most heal spontaneously (especially in children) with conservative management 5
• Healing rates: Resolution rates for middle ear effusion are 30-40% at 2 weeks, 60-70% at 1 month, and 75-90% at 3 months 1
• Diabetic patients: Require closer monitoring due to higher risk of malignant otitis externa 1
• Immunocompromised patients: More susceptible to otomycosis and necrotizing otitis externa 1

Common Pitfalls to Avoid

• Misdiagnosis: Ensure proper differentiation between otitis media with perforated eardrum and external otitis 4
• Water exposure: Failure to keep the ear dry can lead to persistent infection and delayed healing 1, 2
• Delayed referral: Perforations that don't heal within one month should be referred to an otolaryngologist 2, 3
• Overlooking complications: Watch for signs of ossicular chain disruption (vertigo, significant hearing loss) which may require urgent intervention 1, 3