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

Treatment for Ruptured Ear Drum

Most traumatic tympanic membrane perforations heal spontaneously and should be managed with watchful waiting, ear protection, and non-ototoxic topical preparations if infection is present. 1, 2

Initial Assessment and Management

• Confirm the 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, immunocompromised state, or prior radiotherapy 4
• Distinguish tympanic membrane perforation from other causes of otalgia, otorrhea, and inflammation of the external ear canal 5
• Assess pain level and recommend appropriate analgesics based on severity (acetaminophen or NSAIDs for mild to moderate pain; opioid combinations for severe pain) 4

Conservative Management

• Most traumatic perforations heal spontaneously within 6-8 weeks with watchful waiting (95% closure rate) 2
• Keep the ear dry to prevent infection by using ear plugs or cotton balls coated with petroleum jelly when showering 3
• Avoid swimming until the perforation has healed completely 3
• Perform regular follow-up to monitor healing and detect potential complications 6

Medication Considerations

• If infection is present, use only non-ototoxic topical preparations to avoid damage to middle ear structures 3, 4
• Ofloxacin is specifically recommended as a non-ototoxic option for patients with perforated eardrums 4
• Prescribe systemic antibiotics only when there is extension of infection outside the ear canal or in patients with specific host factors (diabetes, immunocompromised state) 5, 4
• For perforations with significant ear canal edema, a wick made of compressed cellulose may be placed to facilitate drug delivery 3

Surgical Intervention

• Consider surgical intervention (tympanoplasty) if the perforation persists for more than 6 months after injury 1, 6
• Early surgical intervention is indicated for:
  • Blast injuries (higher risk of secondary cholesteatoma) 2
  • Early onset facial nerve paralysis 6
  • Suspected perilymphatic fistula with persistent vestibular symptoms 6

Common Pitfalls to Avoid

• Never irrigate the ear canal when tympanic membrane perforation is present or suspected, as this can lead to middle ear infection, vertigo, or ototoxicity 3, 4
• Avoid using alcohol-containing drops or potentially ototoxic preparations that can enter the middle ear through the perforation 3
• Do not use cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind cotton fibers 3
• If the patient fails to respond to initial therapy within 48-72 hours, reassess to confirm the diagnosis and exclude other causes 5, 4

Follow-up Recommendations

• Biannual follow-up for a minimum of two years is recommended due to the risk of cholesteatoma formation 6
• Refer to an ENT specialist if there are alarming signs such as continuous pain, vertigo, facial paralysis, or if the perforation persists beyond the expected healing time 1