Treatment of Otitis Externa with Ruptured Tympanic Membrane
When treating otitis externa with a ruptured tympanic membrane, clinicians should recommend a non-ototoxic topical preparation to prevent potential damage to middle ear structures. 1, 2
Initial Assessment
- Distinguish diffuse acute otitis externa from other causes of otalgia, otorrhea, and inflammation of the external ear canal 3
- Assess for modifying factors that affect management, including non-intact tympanic membrane, diabetes, immunocompromised state, and prior radiotherapy 3, 2
- Avoid irrigation and pneumatic otoscopy in cases of suspected perforation, as these can worsen the injury or introduce infection 2
Treatment Approach
Topical Therapy Selection
- Use only non-ototoxic topical preparations when the tympanic membrane is not intact 3, 1
- Fluoroquinolone preparations (ofloxacin 0.3% or ciprofloxacin 0.2%) are appropriate choices as they are not ototoxic 4, 5
- Never use potentially ototoxic preparations containing aminoglycosides (neomycin or gentamicin) in patients with perforated tympanic membranes 2, 6
Drug Delivery Techniques
- Perform gentle aural toilet (cleaning) using suction under microscopic guidance, especially for diabetic or immunocompromised patients 2
- Consider placing a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 2
- Use compressed cellulose wicks (preferred) or ribbon gauze rather than cotton balls 2
- Remove the wick once ear canal edema subsides, typically within 24-72 hours 2
Pain Management
- Assess pain severity and provide appropriate analgesic treatment, as pain from otitis externa can be intense 3
- Consider using acetaminophen or nonsteroidal anti-inflammatory drugs for mild to moderate pain 3
- For severe pain, fixed combinations with opioids (e.g., oxycodone or hydrocodone with acetaminophen or ibuprofen) may be necessary 3, 2
Special Considerations
Fungal Infections
- Suspect fungal otitis externa (otomycosis) if the patient fails to respond to initial topical antibiotic therapy 3, 2
- Fungal infections can cause tympanic membrane perforation and require specific antifungal treatment 7, 8
- Treatment includes thorough debridement plus topical antifungal therapy 8
Systemic Antibiotics
- Systemic antibiotics are generally not recommended for uncomplicated otitis externa 3
- Consider systemic antibiotics only when there is extension of infection outside the ear canal or in patients with specific host factors (diabetes, immunocompromised state) 3, 2
Follow-up and Monitoring
- Reassess the patient within 48-72 hours if they fail to respond to the initial therapeutic option 3, 2
- Most tympanic membrane perforations secondary to otitis externa will heal spontaneously with proper treatment 7, 8
- If perforation persists, surgical intervention (tympanoplasty or fat-graft myringotomy) may be required 8
Precautions and Ear Protection
- Keep the ear dry to prevent infection 1
- Use ear plugs or cotton balls coated with petroleum jelly when showering 1
- Avoid swimming until the perforation has healed 1
- Avoid using cotton-tipped applicators in the ear canal as they may cause further trauma 1
Evidence on Specific Medications
- Ofloxacin 0.3% otic solution has been shown to be effective in treating otitis externa with non-intact tympanic membranes with clinical cure rates of 75-91% 9
- Ciprofloxacin 0.2% otic solution achieved a 70% clinical cure rate in patients with acute otitis externa after 7 days of treatment 5
- The most common side effects of ofloxacin otic solution include taste perversion (7%), earache (1%), and pruritus (1%) 4