Is neomycin (neomycin) ear drop okay to use in a child with a perforated tympanic membrane from acute otitis media (AOM)?

Neomycin Ear Drops Should Not Be Used in a 7-Year-Old with Perforated Tympanic Membrane from AOM

Neomycin ear drops are contraindicated in patients with perforated tympanic membranes due to the risk of ototoxicity and should not be used in a 7-year-old child with a perforation from acute otitis media. 1

Risks of Neomycin with Perforated Tympanic Membranes

• The FDA drug label explicitly warns that neomycin can induce permanent sensorineural hearing loss due to cochlear damage, mainly through destruction of hair cells in the organ of Corti 1
• Due to its acidity, neomycin solutions may cause burning and stinging and "should not be used in any patients with a perforated tympanic membrane" according to the FDA label 1
• While short-term use of neomycin eardrops in patients with non-intact tympanic membranes may not show increased risk of sensorineural hearing loss, repeated doses (≥2 prescriptions) are significantly associated with increased risk of hearing loss 2
• Despite contraindications, studies show that neomycin otic preparations are still prescribed to approximately 15% of children with non-intact tympanic membranes, highlighting a concerning practice pattern 3

Recommended Alternatives for Perforated Tympanic Membranes

• Quinolone ear drops (such as ciprofloxacin or ofloxacin) have not shown ototoxicity and are recommended over systemic treatment for ear infections with non-intact tympanic membranes 4
• Antibiotic-corticosteroid combination ear drops may be more effective than antibiotic drops alone for treating ear discharge 4, 5
• For acute otitis media with perforation, oral antibiotics may be prescribed instead of potentially ototoxic topical preparations 6
• Common oral antibiotic options for AOM include amoxicillin (first-line), amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 4

Management Approach for AOM with Perforation

1. Initial assessment:

   • Clean the ear canal of any debris or discharge by gentle suctioning (avoid irrigation) 6
   • Document perforation size and location 6
   • Avoid pneumatic otoscopy which could worsen the perforation 6

2. Treatment options:

   • For a 7-year-old with AOM and perforation, oral antibiotics are appropriate 6
   • Amoxicillin is the first-line drug for uncomplicated AOM 7
   • For beta-lactamase-producing strains, consider amoxicillin-clavulanate, cefuroxime-axetil or cefpodoxime-proxetil 4
   • Treatment duration should be 5 days for children older than 2 years 4

3. Precautions:

   • Keep the affected ear dry to allow healing 6
   • Avoid all ototoxic ear drops including neomycin 1
   • Monitor for healing of the perforation; most small perforations resolve spontaneously 6

When to Refer to an Otolaryngologist

• Consider ENT referral if the perforation does not heal within one month 6
• Immediate referral is necessary if there is significant hearing loss, vertigo, or other concerning symptoms suggesting ossicular chain disruption 6
• Persistent ear discharge despite appropriate oral antibiotic therapy warrants specialist evaluation 6

Important Considerations

• The risk of complications from untreated AOM must be balanced against potential ototoxicity from inappropriate topical treatments 8
• In high-income countries, most cases of AOM spontaneously remit without complications, but perforations require appropriate management 8
• Failure of antibiotic therapy (worsening condition, persistence of symptoms >48 hours, or recurrence within 4 days after treatment) may require paracentesis with collection of bacteriological specimen 4