What do I do if a 1-year-old baby has a tympanic membrane (TM) perforation?

Management of Tympanic Membrane Perforation in a 1-Year-Old

For a 1-year-old with tympanic membrane perforation, keep the ear dry and observe for spontaneous healing, which occurs in most cases; if there is active infection or drainage, use topical fluoroquinolone drops (ofloxacin) rather than systemic antibiotics, and refer to ENT if the perforation persists beyond 1 month or if concerning features develop. 1, 2

Immediate Assessment

Confirm the diagnosis and characterize the perforation:

• Perform careful otoscopic examination to document the size and location of the perforation 1, 2
• Do NOT irrigate the ear canal or perform pneumatic otoscopy when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 1
• Gently suction any blood, purulent secretions, or debris from the ear canal 2
• Assess for concerning features that require urgent ENT referral:
  • History of vertigo, nausea, or vomiting (suggests ossicular chain disruption) 2
  • Facial paralysis 3
  • Profound hearing loss (may indicate inner ear damage) 2
  • Continuous severe pain 3

Ear Protection Measures

The most critical intervention is keeping the ear dry to prevent infection:

• Use earplugs or cotton balls coated with petroleum jelly during bathing and showering 1
• Avoid swimming completely until the perforation has healed 1
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma 1

Medical Management

If there is active drainage or signs of infection:

• Use topical fluoroquinolone drops (ofloxacin) as first-line treatment 1, 4
  • For a 1-year-old with perforation: 5 drops (0.25 mL) into the affected ear twice daily for 10-14 days 4
  • Warm the bottle in your hand for 1-2 minutes before instillation to avoid dizziness 4
  • Have the child lie with affected ear upward, instill drops, pump the tragus 4 times, and maintain position for 5 minutes 4
• Avoid ototoxic preparations including neomycin-containing drops, alcohol-containing drops, and aminoglycosides, as these can cause severe hearing loss when entering the middle ear through the perforation 1

Systemic antibiotics are NOT routinely indicated unless there is extension of infection outside the ear canal or the child has specific risk factors like immunocompromised state 1

Follow-Up and Monitoring

Most traumatic perforations heal spontaneously within 1 month:

• Small perforations typically resolve without intervention 2, 3, 5
• Recheck at 2-4 weeks to assess healing 2
• Refer to ENT if:
  • Perforation persists beyond 1 month 2, 3
  • Any alarming signs develop (vertigo, facial paralysis, continuous pain) 3
  • Significant hearing loss is present (>30 dB conductive loss) 2
  • The child fails to respond to initial therapy within 48-72 hours 1

Special Considerations for This Age Group

At 1 year of age, this child is at a critical developmental period:

• Children with perforations are at risk for speech and language delays if hearing is affected 6
• Consider hearing evaluation if the perforation persists beyond 3 months or if there are concerns about developmental impact 6
• All children in published series healed spontaneously, making conservative management appropriate 5

Common Pitfalls to Avoid

• Never use neomycin-containing drops (like Cortisporin) when the tympanic membrane is not intact—severe hearing loss has been documented after prolonged administration through perforations 1
• Do not prescribe oral antibiotics routinely; topical therapy is superior for perforations with drainage 1
• Do not allow water exposure during healing—this is the most common cause of secondary infection 1, 3
• Do not delay ENT referral if concerning features are present, as complications like cholesteatoma can develop 3, 7