What is the treatment for a perforated eardrum?

Treatment of Perforated Eardrum

For a perforated eardrum, mechanical removal of debris is the preferred treatment method, avoiding irrigation which could cause complications in cases of tympanic membrane perforation. 1

Initial Assessment and Management

• Carefully assess the perforation by history and physical examination to determine the cause (trauma, infection), size, and location of the perforation 1
• Keep the ear dry to prevent infection, as moisture can enter the middle ear through the perforation 2
• Avoid irrigation of the ear canal in patients with perforated eardrums as this can cause vertigo and introduce toxins to the middle ear 1
• Use manual removal with appropriate instrumentation (curette, forceps, suction) under direct visualization to clear debris when necessary 1

Treatment Based on Cause

Traumatic Perforations

• Most traumatic perforations heal spontaneously within 1-3 months and require minimal intervention 2, 3
• Keep the ear dry and avoid water exposure by using ear plugs or cotton with petroleum jelly when showering 1
• Avoid inserting anything into the ear canal, including cotton-tipped swabs 1

Infection-Related Perforations

Acute Otitis Media with Perforation:

• Treat with appropriate oral antibiotics 2
• For chronic suppurative otitis media with perforated tympanic membrane in patients 12 years and older:
  • Topical antibiotic therapy: Ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 4
  • Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness 4
  • Patient should lie with affected ear upward during instillation 4
  • Pump the tragus 4 times to facilitate penetration into the middle ear 4
  • Maintain position for five minutes after instillation 4

For Aspergillus Otomycosis with Perforation:

• Topical therapy with irrigating solutions of boric acid, acetic acid, or azole cream may be effective 1
• For refractory cases with perforated tympanic membranes, voriconazole, posaconazole, or itraconazole may be appropriate 1

Monitoring and Follow-up

• Most small perforations heal spontaneously within 1-3 months 3, 5
• Healing rates are generally good (82-95%) regardless of perforation size, though larger perforations take longer to heal 3
• Factors affecting healing:
  • Perforation size (larger perforations take longer to heal) 3
  • Presence of serosanguinous discharge (heals faster than dry perforations) 3
  • Pre-existing tympanosclerosis (most prominent cause of healing failure) 3

When to Refer to an Otolaryngologist

• Perforations that persist beyond one month 5
• Presence of alarming symptoms such as:
  • Continuous pain 2
  • Vertigo 2, 5
  • Facial paralysis 2
  • Significant hearing loss (>30 dB conductive loss) 5
• Chronic perforations that may require surgical repair 2, 6
• Suspicion of cholesteatoma or other unsafe conditions 6

Surgical Options

• Tympanoplasty may be considered for perforations that do not heal spontaneously 1, 6
• Cartilage tympanoplasty provides better structural outcomes (fewer postoperative TM perforations) compared to temporalis muscle fascia, though hearing outcomes are similar 1
• Novel adjuvant therapies such as biomolecules (fibroblast growth factor) with scaffolding materials have shown promising results for chronic perforations 1

Precautions and Contraindications

• Avoid ear irrigation in patients with:
  • Known or suspected tympanic membrane perforation 1
  • History of ear surgery 1
  • Patent tympanostomy tubes 1
  • History of barotrauma 1
  • Current otitis externa 1
• Never use ear candles, as they have no proven efficacy and can cause serious damage 1