What is the treatment for a ruptured eardrum (tympanic membrane perforation)?

Treatment for Ruptured Eardrum (Tympanic Membrane Perforation)

Most traumatic tympanic membrane perforations heal spontaneously within 1-2 months with conservative management, and treatment should focus on keeping the ear dry, preventing infection, and avoiding further trauma while monitoring for complete closure. 1, 2, 3

Initial Assessment and Management

• Confirm the diagnosis through careful otoscopic examination, noting the size and location of the perforation 1
• Assess for pain and provide appropriate analgesics based on severity (acetaminophen or NSAIDs for mild to moderate pain; opioid combinations for severe pain) 4
• Perform gentle aural toilet only when the ear canal is obstructed by debris to enhance delivery of topical medications 4
• Avoid irrigation of the ear canal when tympanic membrane perforation is present or suspected, as this can lead to middle ear infection, vertigo, or ototoxicity 1, 5

Conservative Management

• Keep the ear dry to prevent infection by using ear plugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until the perforation has healed 1
• Most traumatic perforations (89-95%) heal spontaneously within an average of 27.4 days with conservative management 3, 6
• Small perforations have a better healing rate (92%) compared to larger perforations (54%) 6
• Wet perforations with bloody or watery discharge have better healing rates and shorter closure times compared to dry perforations 6

Infection Prevention and Treatment

• If infection is present, use only non-ototoxic topical preparations to avoid potential harm to middle ear structures 1, 4
• Ofloxacin is specifically recommended as a non-ototoxic option for patients with perforated eardrums 4
• Avoid alcohol-containing drops or potentially ototoxic preparations, which can enter the middle ear through the perforation and cause damage 1
• 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 4

Follow-up and Monitoring

• Regular follow-up is essential to monitor healing progress and detect complications 3
• If no improvement is seen within 48-72 hours of treatment for infection, reassess to confirm the diagnosis and exclude other causes 4
• Perforations lasting six months after injury warrant surgical intervention (tympanoplasty) 2
• Biannual follow-up during a minimum of two years is recommended due to the risk of cholesteatoma formation 2

Special Considerations

• Blast injuries, thermal or caustic injuries are less likely to heal spontaneously and may require earlier surgical intervention 2
• Early surgical intervention is needed in cases of:
  • Early onset facial nerve paralysis
  • Suspicion of perilymphatic fistula with persisting or increasing vestibular symptoms
  • Neurosensory hearing loss
  • Vestibular dislocation of the stapes footplate 2
• Perforations that involve malleus or umbo damage may have prolonged healing time (41.6 vs 23.8 days) 6
• Children demonstrate excellent rates of complete spontaneous recovery 7

Common Pitfalls to Avoid

• Avoid using cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind cotton fibers 1
• Never irrigate an ear with a known or suspected tympanic membrane perforation 5, 1
• Avoid using potentially ototoxic ear drops that could damage middle ear structures 1, 4
• Don't neglect follow-up, as complications like cholesteatoma formation can occur even after apparent healing 2