What antibiotic is recommended for a tympanic membrane (TM) rupture?

Antibiotic Recommendations for Tympanic Membrane Rupture

For tympanic membrane (TM) rupture, a non-ototoxic topical antibiotic preparation should be used when antibiotic therapy is indicated, with systemic antibiotics reserved for cases with signs of infection or specific risk factors. 1

Assessment and Initial Management

• TM rupture alone without signs of infection does not require antibiotic therapy 1
• Careful examination is needed to determine if there are signs of acute otitis media (AOM) accompanying the TM rupture 1
• When the TM cannot be adequately visualized due to edema or cerumen, referral to an ENT specialist should be considered rather than empiric antibiotic therapy 1

Antibiotic Selection for TM Rupture with Infection

Topical Therapy

• When using topical therapy, only non-ototoxic preparations should be prescribed to avoid potential hearing loss 1
• Ototoxic drops can cause severe hearing loss with prolonged or repetitive administration in patients with TM perforation 1
• A wick may be placed if ear canal edema prevents medication entry or if most of the TM cannot be visualized 1

Systemic Therapy (if indicated for accompanying AOM)

• First-line: Amoxicillin (80-90 mg/kg/day) 1
• Second-line: Amoxicillin-clavulanate 1
• For penicillin allergy: Cefuroxime-axetil, cefpodoxime-proxetil, or erythromycin-sulfafurazole 1

Treatment Algorithm Based on Clinical Presentation

Scenario 1: TM Rupture Without Signs of Infection

• Observation without antibiotics 1
• Keep ear dry and clean 1
• Follow-up to ensure proper healing 1

Scenario 2: TM Rupture With Signs of AOM

• For children <2 years: Antibiotic therapy recommended 1
• For children >2 years: Antibiotic therapy if marked symptoms (high fever, intense pain) 1
• First-choice: Amoxicillin 80-90 mg/kg/day 1
• Duration: 8-10 days for children <2 years; 5 days for older children 1

Scenario 3: TM Rupture With Severe Infection or Treatment Failure

• Consider amoxicillin-clavulanate, cefpodoxime-proxetil, or cefuroxime-axetil 1
• In cases of treatment failure, consider tympanocentesis with collection of bacteriological specimen 1
• Consider referral to ENT specialist 1

Common Pitfalls to Avoid

• Using ototoxic topical antibiotics in patients with TM perforation can lead to permanent hearing loss 1
• Prescribing antibiotics without adequate visualization of the TM 1
• Failure to distinguish between simple TM rupture (which may not require antibiotics) and TM rupture with AOM (which may require systemic antibiotics) 1
• Not considering the moist environment created by topical drops, which may actually improve healing of traumatic TM perforations 2

Special Considerations

• Ofloxacin otic drops have been shown to shorten closure time and improve closure rate of large traumatic TM perforations without increasing middle ear infection rates 2
• For patients with diabetes or immunocompromised state, atraumatic cleaning with aural suctioning under microscopic guidance may be needed 1
• In cases where antibiotics are indicated, the choice should consider the most likely pathogens: S. pneumoniae, H. influenzae, and M. catarrhalis 1