Neomycin-Polymyxin B Should NOT Be Used in Ruptured Tympanic Membranes
Do not use neomycin-polymyxin B ointment or drops in the ear canal when there is a known or suspected ruptured tympanic membrane, as neomycin is ototoxic and can cause permanent sensorineural hearing loss when it accesses the middle ear structures. 1, 2, 3
Why Neomycin is Contraindicated
The FDA drug label explicitly warns against using neomycin in perforated tympanic membranes, stating it should not be used in any patients with a perforated tympanic membrane due to the risk of permanent sensorineural hearing loss from cochlear damage, mainly destruction of hair cells in the organ of Corti 3
The American Academy of Otolaryngology-Head and Neck Surgery guidelines mandate using only non-ototoxic preparations when the tympanic membrane is not intact to avoid potential harm to middle ear structures 1, 2
Case reports document total hearing loss after neomycin-containing preparations were instilled in ears with perforated tympanic membranes, with one patient experiencing complete hearing loss after using neomycin cream 4, 5
What to Use Instead
Prescribe ofloxacin otic solution (0.3%) as the preferred non-ototoxic alternative for ear infections when tympanic membrane perforation is known or suspected 6, 7
Ofloxacin is specifically recommended by the American Academy of Otolaryngology-Head and Neck Surgery for patients with tympanic membrane perforation 6
Clinical trials demonstrate ofloxacin is as effective as neomycin/polymyxin B/hydrocortisone for treating otitis externa (93.8% vs 94.7% cure rates), with the critical advantage of lacking ototoxicity 8
Ofloxacin requires less frequent dosing (once daily vs four times daily), improving adherence 7, 8
Critical Clinical Pitfalls
Even when you cannot visualize the tympanic membrane due to canal edema or debris, assume a perforation may be present and avoid neomycin 1, 6
If swelling prevents adequate visualization, use tympanometry if possible—a normal type A tracing suggests an intact membrane, but when in doubt, choose the non-ototoxic option 2
Severe hearing loss has been documented after prolonged or repetitive neomycin administration through perforations, though single short courses carry lower risk 1
The risk is particularly high when neomycin accesses the round window membrane without inflammatory edema or secretion acting as a barrier 5
Additional Safety Considerations
Neomycin-containing creams or ointments may be particularly ototoxic compared to drops due to prolonged contact time with middle ear structures 4
The FDA label limits neomycin use to 10 consecutive days maximum even in intact tympanic membranes due to ototoxicity risk 3
Patients with tympanostomy tubes should be treated as having non-intact tympanic membranes—assume tubes are patent for at least 6-12 months after placement 1