Diagnosis and Treatment of Ruptured Tympanic Membrane
The diagnosis of a ruptured tympanic membrane requires otoscopic examination to visualize the perforation, and treatment should focus on keeping the ear dry, avoiding ear irrigation, and allowing for spontaneous healing in most cases, with antibiotic therapy only when infection is present. 1
Diagnosis
Clinical Assessment
- History taking should focus on:
- Mechanism of injury (trauma, infection, foreign body)
- Presence of symptoms: ear pain, hearing loss, tinnitus, fullness, vertigo 1
- Timing of perforation (acute vs. chronic)
- Associated symptoms (discharge, fever, vertigo)
- Risk factors (swimming, ear cleaning, previous ear infections)
Physical Examination
- Otoscopic examination is essential to visualize the tympanic membrane and confirm perforation 2
- Carefully clean ear canal of blood or secretions using gentle suction (NOT irrigation) 1
- Document size and location of perforation
- Assess for middle ear effusion or signs of infection
Diagnostic Tests
- Tuning fork tests (Weber and Rinne) to differentiate conductive from sensorineural hearing loss 2
- Audiometry to assess degree of hearing loss (typically mild conductive loss of <30 dB) 1
- Tympanometry is contraindicated with perforation
Warning Signs Requiring Specialist Referral
- Vertigo, nausea, or vomiting (suggests ossicular chain disruption)
- Conductive hearing loss >30 dB (suggests ossicular damage)
- Profound sensorineural hearing loss (suggests inner ear damage)
- Facial weakness or paralysis
- Persistent pain despite treatment 3, 1
Treatment Approach
Immediate Management
Keep the ear dry - critical for healing 3, 1
- Avoid water exposure
- Use petroleum jelly-coated cotton or earplugs when showering 4
- Avoid swimming until cleared by physician
Avoid harmful practices:
- No ear irrigation or pneumatic otoscopy 1
- No insertion of objects into the ear canal
- No topical drops if not specifically prescribed
Treatment Based on Cause
For Traumatic Perforations:
- Most heal spontaneously within 1-2 months (56 of 60 patients in one study) 5
- Conservative management with observation is appropriate
- Keep ear dry and clean
- Follow-up to ensure healing
For Infection-Related Perforations:
For acute otitis media with perforation:
For chronic perforations with active infection:
Special Considerations
- For significant canal edema: Consider wick placement to facilitate medication delivery 4
- For diabetic or immunocompromised patients: Avoid ear canal irrigation; monitor closely for malignant otitis externa 4
- For children: Higher rate of spontaneous healing (100% in one study) 5
Follow-up and Referral
Follow-up Timeline
- Initial follow-up within 1-2 weeks
- Continue follow-up until complete healing (average 6.2 weeks) 5
- Refer to otolaryngologist if:
Surgical Management
- Reserved for perforations that fail to heal spontaneously
- Tympanoplasty or myringoplasty may be required for chronic perforations 3, 1
- Success rate is high (3 of 3 patients in one study) 5
Complications to Monitor
- Persistent hearing loss
- Recurrent middle ear infections
- Cholesteatoma formation
- Ossicular chain disruption
- Vertigo
Patient Education
- Explain expected timeline for healing (most within 1-2 months)
- Emphasize importance of keeping ear dry
- Advise on proper ear hygiene and avoiding trauma
- Discuss warning signs requiring prompt medical attention