How do ENTs treat otitis media with a perforated tympanic membrane?

Treatment of Otitis Media with Perforated Tympanic Membrane

For otitis media with a perforated tympanic membrane, ENTs primarily treat with topical antibiotics such as ofloxacin otic solution administered as 10 drops (0.5 mL) twice daily for fourteen days in patients 12 years and older. 1

Initial Management

• Accurate diagnosis is essential to reduce over-diagnosis and overtreatment of otitis media in its various forms 2
• The ear canal should be carefully suctioned to remove blood, purulent secretions, and debris, while avoiding irrigation and pneumatic otoscopy which could worsen the perforation 3
• Most small perforations resolve spontaneously, and the affected ear should be kept dry during the healing process 3

Pharmacological Treatment

• For chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older, ofloxacin otic solution is administered as 10 drops (0.5 mL) twice daily for fourteen days 1
• For pediatric patients (1-12 years old) with tympanostomy tubes and acute otitis media, five drops (0.25 mL) of ofloxacin otic solution twice daily for ten days is recommended 1
• Topical antibiotics are preferred over systemic antibiotics for perforated tympanic membranes with infection, as they achieve higher concentrations at the infection site with fewer systemic side effects 4
• Clinical cure rates with ofloxacin otic solution in chronic suppurative otitis media are significantly higher (91%) compared to historical treatment approaches (67-70%) 5

Ineffective Treatments to Avoid

• Systemic antibiotics are not routinely recommended for uncomplicated perforated tympanic membrane without signs of active infection 6
• Antihistamines and decongestants are ineffective for middle ear effusion and should not be used 6
• Oral or topical steroids are not recommended for routine management of middle ear effusion 6

Surgical Management

• For persistent perforations that do not heal within one month, otolaryngologic referral may be necessary 3
• Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations show promising results 6
• Two systematic literature reviews compared temporalis muscle fascia with cartilage tympanoplasty, finding better structural outcomes (fewer postoperative TM perforations) with cartilage grafts, though functional outcomes (hearing) were similar 2
• Tissue-engineered myringoplasty using a gelatin sponge scaffold soaked in fibroblast growth factor (b-FGF) has shown significantly higher closure rates compared to gelatin sponge alone 2

Special Considerations

• Perforations associated with vertigo or significant hearing loss require prompt otolaryngologic referral 3
• For otomycosis involving perforated tympanic membranes, voriconazole, posaconazole, or itraconazole may be appropriate when topical treatments with boric acid or acetic acid are ineffective 2
• Follow-up should occur at 3-6 month intervals until the effusion resolves or significant hearing loss is identified 6
• The most common side effect of topical ofloxacin is bitter taste (17% of patients), particularly in those with non-intact tympanic membranes 5

Proper Administration Technique

• The solution should be warmed by holding the bottle in hand for 1-2 minutes to avoid dizziness from instilling cold solution 1
• The patient should lie with the affected ear upward before instilling the drops 1
• The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear 1
• This position should be maintained for five minutes to ensure proper drug delivery 1