What is the management of eardrum rupture?

Management of Eardrum Rupture

Initial Management: Watchful Waiting is the Primary Approach

Most traumatic tympanic membrane perforations (95-99%) heal spontaneously with conservative management, making watchful waiting the preferred initial strategy for uncomplicated cases. 1, 2

Immediate Assessment

• Confirm the diagnosis through otoscopic examination to visualize the perforation, document its size and location (most commonly upper anterior and lower posterior quadrants), and assess for any signs of infection or middle ear involvement 1
• Evaluate for complications including hearing loss, vertigo, tinnitus, or signs of ossicular chain injury 3
• Identify the mechanism of injury: blast injuries carry higher risk of secondary cholesteatoma and may require surgical exploration, unlike simple trauma from impact, barotrauma, or foreign bodies 1

Conservative Management Protocol

Observation Strategy

• Keep the ear dry by avoiding water entry into the ear canal; cover with an earplug or cotton with petroleum jelly during showering or hair washing 4
• Avoid inserting anything into the ear canal, including cotton-tipped swabs, which can cause further injury or introduce infection 4
• Do not use ear candles, as they provide no benefit and can cause serious harm including further perforation 4

Antibiotic Use

• Antibiotics are not routinely necessary for clean traumatic perforations without signs of infection 1
• Topical antibiotic drops (such as ofloxacin) may be beneficial for larger perforations, as they create a moist environment that shortens closure time and improves healing rates without increasing infection risk 5
• Use only ototopically-safe preparations if the tympanic membrane integrity is compromised 4

Expected Healing Timeline

• Most perforations close within weeks to months under conservative management, with 95% achieving complete closure 1
• Medium-sized perforations typically heal faster with topical ofloxacin drops (mean closure time significantly reduced) 5
• Large perforations show improved closure rates (statistically significant) with moist therapy using topical drops 5

Alternative Interventions

Micropore Tape Patching

• Consider tape patching for fresh traumatic perforations as a simple, reliable method with 99% success rate that requires no anesthesia 2
• This technique involves placing a small piece of micropore strip tape over the perforation to support healing 2

Surgical Intervention

• Tympanoplasty is reserved for perforations that fail to heal spontaneously after appropriate observation period (typically several months) 3
• Immediate surgical exploration is indicated for blast injuries due to the risk of secondary cholesteatoma formation 1
• Consider surgery if there is suspected ossicular chain disruption with persistent conductive hearing loss 3

Activity Restrictions

• Prohibit swimming until the perforation heals completely, as water exposure increases infection risk, particularly in polluted water 3
• Avoid diving and activities causing pressure changes (scuba diving, flying) until healing is confirmed 3
• No nose blowing or Valsalva maneuvers that could disrupt healing or introduce infection 3

Follow-Up Requirements

• Schedule otoscopic examination every 2-4 weeks to monitor healing progress and detect complications early 1
• Perform audiometry once healed to document hearing recovery and rule out ossicular injury 3
• Refer to otolaryngology if perforation persists beyond 2-3 months, hearing loss continues, or signs of infection develop 1

Key Pitfalls to Avoid

• Do not irrigate the ear with water or cerumen-removing solutions when perforation is present or suspected 4
• Avoid prescribing anesthetic eardrops as they are not intended for active infections and can mask treatment failure 4
• Do not assume all perforations are benign: blast injuries require different management due to cholesteatoma risk 1
• Never delay referral for persistent otorrhea, progressive hearing loss, or vertigo suggesting inner ear involvement 3