What is the initial management for a ruptured tympanic membrane in the emergency department (ED)?

Emergency Department Management of Tympanic Membrane Rupture

For initial management of a ruptured tympanic membrane in the emergency department, clinicians should assess for pain, perform careful aural toilet without irrigation, and prescribe a non-ototoxic topical preparation if infection is present, while keeping the ear dry to promote healing.

Initial Assessment and Pain Management

• The clinician should assess patients with tympanic membrane rupture for pain and recommend analgesic treatment based on the severity of pain 1
• Pain may be severe due to the highly sensitive periosteum of the underlying bone in close proximity to the ear canal skin 1
• Use appropriate analgesics at adequate doses (acetaminophen or NSAIDs for mild to moderate pain; opioid combinations for severe pain) 1
• Administer analgesics on a scheduled basis as pain is easier to prevent than treat 1

Examination and Cleaning

• Carefully examine the ear canal and tympanic membrane to determine the size and location of the perforation 2
• Blood, purulent secretions, and debris should be carefully suctioned out of the ear canal 2
• Avoid irrigation and pneumatic otoscopy in patients with tympanic membrane perforation as these can cause further damage or introduce infection 2
• Perform aural toilet when the ear canal is obstructed by debris to enhance delivery of topical medications 1

Topical Treatment for Infection

• When infection is present with a perforated tympanic membrane, clinicians should recommend a non-ototoxic topical preparation 1
• Ofloxacin is specifically recommended as a non-ototoxic option for patients with perforated eardrums 3
• Avoid potentially ototoxic preparations in patients with known or suspected tympanic membrane perforation 3
• If the tympanic membrane cannot be fully visualized due to swelling or discharge, it is safest to use non-ototoxic preparations 3

Keep the Ear Dry

• Since perforation predisposes to infections, it is important to keep the ear dry 4
• Instruct patients to avoid getting water in the affected ear during bathing or swimming 4
• Consider placing a cotton ball coated with petroleum jelly in the outer ear canal during showering 2

Follow-up and Referral Considerations

• Most small perforations resolve spontaneously within 1-2 months 2, 5
• If the patient fails to respond to the initial therapeutic option within 48-72 hours, the clinician should reassess to confirm the diagnosis and exclude other causes 1
• Consider ENT referral for:
  • Perforations associated with vertigo or significant hearing loss 2
  • Perforations from chronic otitis media 2
  • Perforations that do not heal within one month 2
  • Presence of alarming signs such as continuous pain, vertigo, or facial paralysis 4

Special Considerations

• Assess for modifying factors that may affect management (diabetes, immunocompromised state, prior radiotherapy) 1
• For traumatic perforations, most heal spontaneously, especially in children 5
• If systemic antibiotics are needed (such as with concurrent acute otitis media or extension outside the ear canal), they should be prescribed in addition to, not instead of, appropriate topical therapy 1