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 with conservative management, requiring only watchful waiting and ear protection measures. 1, 2

Initial Assessment and Management

• Confirm diagnosis through careful otoscopic examination, noting the size and location of the perforation 3
• Assess for modifying factors that may influence management, such as diabetes or immunocompromised state 3
• Carefully suction blood, purulent secretions, and debris from the ear canal 4
• Avoid ear irrigation when tympanic membrane perforation is present or suspected, as this can lead to middle ear infection, vertigo, or ototoxicity 3

Conservative Management (First-Line Approach)

• Watchful waiting is appropriate for most traumatic perforations, with approximately 95% healing spontaneously within 4-6 weeks 1, 2
• 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 3
• Avoid using cotton-tipped applicators in the ear canal as they may cause further trauma 3

Medication Considerations

• If topical preparations are needed (such as for infection), use only non-ototoxic preparations to avoid potential harm to middle ear structures 3, 5
• For perforations with significant edema of the ear canal, a wick made of compressed cellulose may be placed to facilitate drug delivery 3
• Avoid alcohol-containing drops or potentially ototoxic preparations, which can enter the middle ear through the perforation and cause damage 3
• Oral antibiotics may be prescribed for perforations related to acute otitis media 4

Follow-Up and Monitoring

• Regular follow-up is recommended until complete healing occurs, typically within 4-6 weeks 1, 2
• Biannual follow-up for a minimum of two years is recommended due to the risk of cholesteatoma formation 6

Surgical Intervention (When Needed)

• Consider surgical intervention (tympanoplasty) for:
  • Perforations that persist for more than 6 months after injury 6
  • Early onset facial nerve paralysis 6
  • Suspicion of perilymphatic fistula with persisting or increasing vestibular symptoms 6
  • Neurosensory hearing loss 6
  • Vestibular dislocation of the stapes footplate 6

Factors Affecting Healing

• Wet perforations with bloody or watery discharge tend to heal faster than dry perforations 7
• Larger perforations (>50% of the tympanic membrane) have lower spontaneous healing rates (54% vs. 92% for small perforations) and longer healing times 7
• Perforations involving malleus or umbo damage may take longer to heal (41.6 vs. 23.8 days) 7
• Blast injuries are less likely to heal spontaneously compared to other traumatic causes 6

Special Considerations

• Children show excellent prognosis with complete spontaneous recovery in most cases 2
• High-resolution CT scan of the temporal bone is required for immediate complete facial nerve paralysis or suspected oval window pathology 6