Prednisone Ear Drops for Bulging Tympanic Membrane
For bulging tympanic membrane, intratympanic dexamethasone at concentrations of 10-24 mg/mL or methylprednisolone at 30-40 mg/mL is recommended, with 0.4-0.8 mL injected into the middle ear space for 3-4 sessions every 3-7 days depending on clinical response. 1
Dosing Recommendations
For intratympanic steroid therapy, either dexamethasone or methylprednisolone can be used with the following concentrations 1:
- Dexamethasone: 4-24 mg/mL (stock) or 16-24 mg/mL (compounded)
- Methylprednisolone: 30-40 mg/mL (stock) or 62.5 mg/mL (compounded)
Higher concentrations of steroids appear to have better outcomes, with one study showing 53% of patients using 24 mg/mL dexamethasone had >30-dB improvement compared to only 17% with 10 mg/mL 1
Administration technique 1:
- Inject 0.4-0.8 mL into the middle ear space
- Keep the patient's head in otologic position (affected ear up) for 15-30 minutes
- Treatment frequency ranges from once only to 3-4 sessions every 3-7 days depending on clinical response
Monitoring and Follow-up
- Perform audiogram at completion of treatment course and at delayed intervals 1
- Interval audiograms between injections may help direct early termination of therapy if hearing loss resolves 1
- Inspect tympanic membrane to ensure healing at completion of treatment course and at a delayed interval 1
Potential Adverse Effects
Intratympanic steroids have fewer systemic side effects than oral steroids but can still cause local adverse effects 1:
- Pain during or after injection
- Transient dizziness
- Risk of infection
- Persistent tympanic membrane perforation
- Possible vasovagal or syncopal episode during injection
Topical steroids may delay tympanic membrane healing, as demonstrated in animal studies 2, 3:
Clinical Considerations
A pressure-equalizing tube may be inserted if planning multiple injections, but this increases the risk of tympanic membrane perforation 1
For patients who cannot receive systemic steroids (insulin-dependent or poorly controlled diabetes, labile hypertension, glaucoma, tuberculosis, peptic ulcer disease, prior psychiatric reactions), intratympanic steroid injections provide a viable alternative 1
The American Academy of Otolaryngology-Head and Neck Surgery suggests that topical therapy delivers a high concentration of medication directly to the affected area 4
For otitis media with effusion, oral prednisone has shown some efficacy at doses of 1 mg/kg/day for the first two days, followed by 0.75 mg/kg/day for two days, then 0.5 mg/kg/day as a single morning dose for the remaining three days 5
Important Caveats
Steroid therapy should be initiated early for maximum benefit 1
Avoid using topical anesthetic drops if a tympanostomy tube is present or if there is uncertainty regarding the integrity of the tympanic membrane, as these drops are not approved for use in the middle ear 1
Most serious side effects of steroids occur with chronic use, and adverse events are rare and manageable for short courses 1
The evidence for systemic corticosteroids in acute otitis media is of low to very low quality, meaning their effect on important clinical outcomes remains uncertain 6