What is the treatment for an infant with a ruptured eardrum (tympanic membrane perforation)?

Treatment of Ruptured Eardrum in Infants

For an infant with a ruptured eardrum, the primary approach is watchful waiting with strict ear protection, as 95% of traumatic perforations heal spontaneously without intervention. 1

Immediate Management

Confirm the Diagnosis

• Perform careful otoscopic examination to visualize the perforation, noting its size and location 2
• Most traumatic perforations are small (Griffin grade I in 97% of cases) and located in the anterior or posterior quadrants 1

Implement Ear Protection Measures

• Keep the ear completely dry to prevent secondary infection 2
• Use cotton balls coated with petroleum jelly during bathing 2
• Avoid any water exposure including swimming until complete healing occurs 2
• Never irrigate the ear canal, as this can cause middle ear infection, vertigo, or ototoxicity 2

When to Use Antibiotics

Topical Antibiotic Therapy (Preferred When Infection Present)

If drainage or signs of infection develop, use topical fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) exclusively 2

• Clean the ear canal first by gentle suctioning of debris before drop administration 2
• Have the infant lie with affected ear up for 3-5 minutes after instillation 2
• Limit treatment to maximum 10 days to prevent fungal overgrowth 2
• Never use aminoglycoside-containing drops (neomycin, gentamicin) as they cause severe hearing loss through perforations 2

Systemic Antibiotics (Reserved for Specific Situations)

Add oral antibiotics only when: 2

• Cellulitis of the pinna or surrounding skin develops
• The infant has diabetes or immunocompromised state
• Signs of severe systemic infection are present
• Topical therapy fails after 48-72 hours despite adequate delivery

Follow-Up Protocol

Monitoring Schedule

• Reassess at 48-72 hours if infection was present to confirm response 2
• Schedule follow-up every 4-6 weeks until complete healing documented 1, 3
• Continue biannual follow-up for minimum 2 years after healing, as traumatic perforations carry risk of cholesteatoma formation 4

Expected Timeline

• Most perforations heal spontaneously within 6-8 weeks 1, 3
• Children have excellent healing rates, with all pediatric cases in one series healing spontaneously 3
• If perforation persists beyond 6 months, surgical repair (myringoplasty) is indicated 4

Critical Pitfalls to Avoid

• Never use cotton-tipped applicators in the ear canal as they cause further trauma 2
• Never use alcohol-containing or ototoxic preparations (aminoglycosides, neomycin) which damage middle ear structures 2
• Do not irrigate the ear canal under any circumstances 2
• Avoid prescribing oral antibiotics as first-line therapy, as topical therapy achieves 1000 times higher drug concentrations at the infection site 2

Special Considerations for Blast Injuries

If the perforation resulted from blast trauma (rare in infants), surgical exploration is indicated rather than watchful waiting due to high risk of secondary cholesteatoma formation 1