What is the treatment for a perforated ear drum?

Management of Perforated Ear Drum

The treatment for a perforated ear drum primarily involves keeping the ear dry, avoiding irrigation, using non-ototoxic topical preparations when infection is present, and allowing for spontaneous healing in most cases. 1

Initial Assessment

• Accurate diagnosis is essential to determine the cause and extent of the perforation 2
• Avoid irrigation and pneumatic otoscopy in cases of suspected perforation as these can worsen the injury or introduce infection 1, 3
• Tympanometry can be considered if swelling or discomfort don't preclude its use, with a normal type A tracing suggesting an intact tympanic membrane 1

Treatment Approach

Conservative Management

• Most acute tympanic membrane perforations heal spontaneously within 1-3 months 4, 5
• Keep the affected ear dry to prevent infection 1, 4
• Avoid water entry into the ear canal during bathing or swimming 1
• Patient should be instructed to report development of otorrhea or otalgia promptly 2

Medication Management

• For perforations with associated infection:
  • Use only non-ototoxic topical preparations when the tympanic membrane is not intact 1
  • For chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older: Ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 6
  • Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness 6
  • Patient should lie with affected ear upward during instillation 6
  • Pump the tragus 4 times to facilitate penetration into the middle ear 6
  • Maintain position for five minutes 6

Surgical Management

• Surgical repair (myringoplasty or tympanoplasty) should be considered for:
  • Perforations that do not heal spontaneously within 1-3 months 5, 3
  • Perforations associated with significant hearing loss 3
  • Chronic perforations associated with recurrent infections 5
• Novel adjuvant treatments for enhancing TM perforation repair include:
  • Biomolecules to stimulate growth of perforation edges 1
  • Bioengineered scaffolds 1, 7
  • Tissue-engineered myringoplasty with basic fibroblast growth factor (b-FGF) 1
  • Mesenchymal stem cells for tissue regeneration 7

Special Considerations

• Traumatic perforations have better prognosis for spontaneous healing than those caused by infection 4, 5
• Perforations caused by acute otitis media should be treated with appropriate antibiotics 4
• Chronic perforations due to chronic middle ear infection or cholesteatoma typically will not heal without surgery 4
• For diabetic patients or immunocompromised individuals with ear infections, consider atraumatic cleaning with aural suctioning under microscopic guidance 1
• Otolaryngologic referral is necessary for:
  • Traumatic perforations associated with vertigo or significant hearing loss 3
  • Perforations from chronic otitis media 3
  • Perforations from acute otitis media that do not heal within one month 3
  • Presence of alarming signs such as continuous pain, vertigo, or facial paralysis 4

Warning Signs Requiring Specialist Referral

• Vertigo, nausea, and vomiting (suggesting ossicular chain disruption) 3
• Conductive hearing loss greater than 30 dB 3
• Profound sensorineural hearing loss (may indicate inner ear or nerve damage) 3
• Continuous pain not responding to treatment 4
• Facial paralysis 4
• Persistent perforation beyond one month 3