What is the assessment and treatment for a 60-year-old male with ruptured eardrums, experiencing continuous loud noise in both ears, who has been taking ofloxacin (fluoroquinolone antibiotic) for 15 days with no relief?

Assessment and Management of Bilateral Tympanic Membrane Perforation with Persistent Tinnitus

Immediate Assessment

Stop ofloxacin immediately—this fluoroquinolone is potentially ototoxic with prolonged use in patients with perforated tympanic membranes and may be contributing to the persistent tinnitus. 1

Critical Diagnostic Considerations

• Verify the diagnosis: Confirm bilateral tympanic membrane perforations through direct visualization with otoscopy, as canal edema may have obscured initial examination 1

• Rule out necrotizing (malignant) otitis externa: This 60-year-old male is in the high-risk age group for this aggressive infection that can present similarly to acute otitis externa but requires fundamentally different management 1

  • Look specifically for granulation tissue at the bony-cartilaginous junction of the ear canal 1
  • Assess for diabetes or immunocompromised state, which dramatically increases risk 1
  • Evaluate for severe, unremitting pain disproportionate to examination findings 1
  • Check for cranial nerve involvement, particularly facial nerve paralysis 1

• Assess for fungal superinfection (otomycosis): Common after prolonged topical antibiotic therapy, particularly in this setting of treatment failure 1

  • Examine for thick white, black, gray, or bluish-green debris in the canal 1
  • Otomycosis presents with pruritus and thickened otorrhea rather than improvement 1

• Evaluate the tinnitus etiology: The "continuous loud noise" may represent:

  • Ototoxicity from prolonged fluoroquinolone use in the setting of perforated membranes 1
  • Underlying sensorineural hearing loss requiring audiometric evaluation
  • Middle ear pathology beyond simple perforation

Treatment Algorithm

Step 1: Discontinue Current Therapy

• Immediately stop ofloxacin 1
• Clinical experience shows severe hearing loss can occur after prolonged or repetitive administration of topical fluoroquinolones through perforated tympanic membranes 1

Step 2: Switch to Non-Ototoxic Topical Therapy

When tympanic membrane perforation is confirmed, prescribe only non-ototoxic topical preparations 1

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends non-ototoxic preparations for perforated membranes, though the guidelines do not specify which agents are non-ototoxic 1. Based on first principles and the preponderance of benefit over harm:

• Consider topical fluoroquinolone solutions specifically labeled as safe for middle ear use (though this creates a clinical dilemma given the current failure)
• Alternatively, perform atraumatic debridement under microscopic guidance and consider systemic antibiotics if topical therapy continues to fail 1

Step 3: Obtain Cultures

• Perform tympanocentesis or culture of middle ear drainage to guide targeted therapy, especially after treatment failure 2
• This is particularly important given the 15-day treatment failure and need to identify resistant organisms or fungal pathogens 1, 2

Step 4: Consider Systemic Antibiotics

If severe symptoms persist or necrotizing otitis externa is suspected:

• Add systemic antibiotics with coverage for Pseudomonas aeruginosa and Staphylococcus aureus (including MRSA) 1
• This is especially critical if the patient has diabetes or immunocompromised state 1

Step 5: Audiometric Evaluation

• Obtain baseline audiometry immediately to document any existing hearing loss or ototoxicity 1
• The persistent "loud noise" (tinnitus) warrants formal hearing assessment
• Follow-up audiometry should be performed 2 months after treatment completion 1

Critical Pitfalls to Avoid

1. Do not irrigate the ear canal: Lavage with tap water is a potential iatrogenic factor for necrotizing otitis externa, particularly in this age group 1

2. Do not continue ototoxic antibiotics: Prolonged use of fluoroquinolones through perforated membranes carries risk of permanent hearing loss 1

3. Do not assume simple infection: At 60 years old with bilateral perforations and treatment failure, consider more serious pathology including necrotizing otitis externa, which requires CT/MRI imaging and aggressive systemic therapy 1

4. Do not use topical antifungals if bacterial infection is confirmed: Conversely, topical antibiotics are contraindicated if otomycosis is diagnosed, as they promote further fungal overgrowth 1

Specialist Referral Indications

Refer to otolaryngology urgently if:

• Necrotizing otitis externa is suspected (requires surgical debridement and IV antibiotics) 1
• Tympanocentesis is needed for culture-directed therapy 2
• Symptoms persist despite appropriate antibiotic switch 2
• Audiometry reveals significant hearing loss requiring specialized management 1

The combination of bilateral perforations, treatment failure after 15 days, and persistent severe tinnitus in a 60-year-old male represents a complex clinical scenario that likely requires subspecialty otolaryngology evaluation for definitive diagnosis and management 1, 2.