What is the diagnosis and management for a 25-year-old female with a 3-day history of fever, cough, and colds, followed by severe right ear pain with bleeding, who used Gentamicin (gentamicin) ear drops and experienced recurrence of bleeding?

Diagnosis: Acute Otitis Media with Tympanic Membrane Perforation

This patient has acute otitis media (AOM) with spontaneous tympanic membrane perforation, and the gentamicin ear drops she used are contraindicated and likely caused the recurrent bleeding—she must stop them immediately and receive appropriate otic therapy with a non-ototoxic agent approved for middle ear use.

Clinical Reasoning

The clinical presentation is classic for AOM progressing to perforation:

• Initial phase: 3 days of upper respiratory infection symptoms (fever, cough, colds) followed by severe ear pain indicates middle ear infection with pressure buildup 1
• Perforation event: Sudden bleeding with subsequent pain improvement suggests spontaneous tympanic membrane rupture, which releases pressure and allows purulent drainage 1
• Recurrent bleeding after gentamicin: This strongly indicates the drops are irritating exposed middle ear mucosa through the perforation 2

The key diagnostic error here was self-medication with gentamicin drops without knowing the tympanic membrane status. If the patient can taste the ear drops, this confirms tympanic membrane perforation, as medication passes through to the middle ear and Eustachian tube 3.

Critical Management Steps

Immediate Actions

1. Stop gentamicin drops immediately 2

   • Gentamicin is vestibulotoxic and cochleotoxic when it reaches the middle ear through a perforation 2
   • Ototoxicity typically occurs after >7 days of use, but damage can begin earlier 2
   • The bleeding recurrence after gentamicin use indicates middle ear mucosal irritation 2

2. Prescribe appropriate otic therapy

   • Use only fluoroquinolone otic drops (ciprofloxacin or ofloxacin) that are FDA-approved for middle ear use with perforations 4, 3
   • These are the only topical antibiotics proven safe when tympanic membrane integrity is compromised 4
   • Administer drops with patient lying affected ear up for 3-5 minutes, pumping the tragus 4 times to facilitate middle ear penetration 3
   • Continue for 7-10 days 3

3. Provide adequate analgesia

   • Prescribe oral NSAIDs or acetaminophen for the first 48-72 hours 1
   • Pain should improve within 48-72 hours of appropriate therapy 1

Follow-up and Monitoring

• Reassess at 48-72 hours if pain does not improve or drainage persists 1, 3
• Examine tympanic membrane at 2-4 weeks to confirm perforation healing
• Audiometric testing if hearing does not normalize after infection resolves, as gentamicin exposure warrants cochlear assessment 2, 5
• Vestibular assessment if patient develops dizziness, imbalance, or oscillopsia, as gentamicin primarily causes vestibulotoxicity 2, 6

Critical Pitfalls to Avoid

Never use aminoglycoside-containing ear drops (gentamicin, tobramycin, neomycin) when tympanic membrane perforation is suspected or confirmed 2. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends checking tympanic membrane integrity before prescribing topical therapy for this exact reason 1.

Other aminoglycoside preparations are equally dangerous:

• Systemic absorption occurs through middle ear mucosa 5
• Vestibular damage is often permanent and debilitating 2, 6
• Even single doses can cause ototoxicity in susceptible individuals 6
• Damage is primarily vestibular rather than cochlear, though both can occur 2

Do not use steroid-only drops or mineral oil, as 98% of acute otitis externa/media cases are bacterial and require antimicrobial coverage 1.

Patient Education

• Keep the ear dry during treatment—use cotton with petroleum jelly when showering 4, 3
• Do not insert cotton swabs or other objects into the ear canal 4
• Expect improvement within 48-72 hours; contact physician if symptoms worsen or fail to improve 1, 3
• Complete the full 7-10 day course even if symptoms resolve earlier 3
• Report immediately if dizziness, imbalance, or hearing changes develop, as these may indicate gentamicin ototoxicity 2, 6