Steroid Use with Tympanic Membrane Perforations
Steroids should generally be avoided in patients with tympanic membrane perforations due to the risk of persistent perforation, though in certain clinical scenarios, non-ototoxic preparations may be cautiously used when benefits outweigh risks.
Risk of Persistent Perforation
- Intratympanic (IT) steroid therapy carries a risk of persistent tympanic membrane perforation at the injection site, though this complication is generally rare and often resolves spontaneously or with a paper patch myringoplasty 1
- Studies show that repeated IT steroid injections significantly increase the risk of persistent tympanic membrane perforations, with hazard ratios increasing with the number of injections (HR=7.95 for first injection, rising to HR=17.47 for fifth or higher injection) 2
- Topical steroids may hinder tympanic membrane healing, as demonstrated in animal models where dexamethasone increased the odds of persistent perforation by 5.5 times compared to antibiotic-only treatment 3
Clinical Considerations for Steroid Use
- When a perforation is present or suspected, clinicians should prescribe a non-ototoxic topical preparation to avoid potential hearing damage 1
- The principal risk of IT steroid therapy appears to be persistent tympanic membrane perforation, which requires careful consideration of risk-benefit ratio 1
- Topical steroid-antibiotic combinations show a small but statistically significant increased risk of requiring subsequent tympanoplasty compared to antibiotic-only treatments (1.12% vs 0.76% in infected perforations; 6.87% vs 5.67% in non-infected perforations) 4
Factors Affecting Perforation Risk
- Tympanic anesthesia with solutions containing phenol significantly increases the risk of perforation after intratympanic steroid injection (odds ratio: 20.76), suggesting these should be avoided 5
- The overall rate of tympanic membrane perforations after intratympanic steroid injection is approximately 12.7% initially, decreasing to 9.3% at 1-month and 5.9% at 3-month follow-up 5
- Patients who undergo myringotomy and tube placement for home-based dexamethasone instillation appear to have a significantly increased incidence of tympanic membrane perforations 6
Alternative Administration Methods
- If steroids are deemed necessary in patients with perforations, consider:
- Systemic administration rather than topical or intratympanic routes 1
- For intratympanic delivery, steroids may be administered via a needle through the tympanic membrane, through a tympanostomy tube, or via a myringotomy 1
- Alternative delivery methods include microcatheters, MicroWick, hydrogel applications, and nanoparticles, though transtympanic needle or tympanostomy tubes are most frequently used 1
Benefits of Intratympanic Steroids (When Appropriate)
- IT steroid therapy provides higher inner ear steroid concentrations compared to systemic administration 1
- IT steroids avoid the systemic side effects of oral steroids, making them suitable for patients with diabetes, cataracts, myasthenia gravis, and glaucoma 1
- For sudden sensorineural hearing loss, IT steroids may be considered as salvage therapy when systemic steroids fail, with improvement rates ranging from 15.4% to 75% depending on timing and protocol 1
Clinical Decision-Making
- When considering steroids in patients with tympanic membrane perforation, carefully weigh the potential benefits against the increased risk of persistent perforation 4
- For otitis media with effusion, steroids (intranasal or systemic) are strongly recommended against due to preponderance of harm over benefit 1
- In cases where the tympanic membrane cannot be fully visualized due to swelling, tympanometry can help establish the presence of an intact membrane 1
- Consider the patient's underlying condition, perforation size, and treatment urgency when deciding on steroid use 1