What is the treatment for bilateral ear perforation?

Treatment of Bilateral Tympanic Membrane Perforation

The primary treatment for bilateral ear perforation is to keep both ears completely dry, use only non-ototoxic topical fluoroquinolone antibiotics if infection develops, and allow spontaneous healing in most cases, with surgical repair (bilateral myringoplasty) reserved for perforations that fail to heal after conservative management. 1, 2

Immediate Conservative Management

Keep Ears Dry (Most Critical Intervention)

• Maintaining dry ears is the single most important measure to prevent secondary infection and allow healing 1, 2
• Instruct patients to use earplugs or cotton balls coated with petroleum jelly when showering 2
• Prohibit swimming completely until perforations heal 2
• Avoid water exposure in both ears 1, 3

Avoid Harmful Interventions

• Never irrigate the ear canal when perforation is present or suspected—this can cause middle ear infection, vertigo, or ototoxicity 4, 1, 2, 5
• Avoid pneumatic otoscopy, which can worsen perforation or introduce infection 1, 2, 5
• Do not use cotton-tipped applicators as they may cause further trauma 2

Medical Management When Infection is Present

Topical Antibiotic Selection (Critical Safety Issue)

• Use ONLY fluoroquinolone ototopical preparations (ofloxacin 0.3% or ciprofloxacin) as these are non-ototoxic even with middle ear exposure 1, 2, 6
• Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations)—these cause severe, irreversible hearing loss when administered through perforations 4, 1, 2
• Avoid alcohol-containing drops as they can enter the middle ear and cause damage 2

Ofloxacin Dosing for Perforated Tympanic Membranes

• For chronic suppurative otitis media with perforation in patients ≥12 years: Ten drops (0.5 mL) into each affected ear twice daily for 14 days 6
• Warm the bottle in hand for 1-2 minutes before instillation to avoid dizziness 6
• Patient should lie with affected ear upward, pump tragus 4 times after instillation, maintain position for 5 minutes 6
• Repeat for opposite ear in bilateral cases 6

When to Use Antibiotics

• Prescribe topical antibiotics only if signs of infection develop (otorrhea, pain, inflammation) 2
• Do not use systemic antibiotics unless infection extends outside the ear canal or patient has diabetes/immunocompromised state 2
• Clean ear canal by suctioning debris before applying medications to enhance drug delivery 4, 2

Monitoring and Follow-Up

Timeline for Reassessment

• Most small traumatic perforations resolve spontaneously 3, 5
• Reevaluate at 48-72 hours if infection is present to confirm response to therapy 2
• Reevaluate at 2 weeks if symptoms persist or perforation has not begun healing 1, 2
• Refer to ENT if perforation persists beyond 1 month 3, 5

Hearing Assessment

• Document hearing status with age-appropriate audiologic testing when feasible 4
• Perforations typically cause mild conductive hearing loss 5
• Conductive hearing loss >30 dB suggests ossicular chain disruption requiring urgent ENT referral 5

Surgical Management for Persistent Bilateral Perforations

Indications for Bilateral Myringoplasty

• Bilateral myringoplasty is safe and effective for chronic bilateral perforations that fail conservative management, with 94% closure rates and no risk of iatrogenic sensorineural hearing loss 7
• Perforations from chronic middle ear infection or cholesteatoma will usually not heal without surgery 3
• Surgery is cost-effective when performed bilaterally under the same anesthetic 8, 7

Surgical Techniques and Outcomes

• Cartilage reconstruction provides superior structural outcomes compared to temporalis fascia, with better graft integration rates 1
• Onlay technique with fascia (56%), tragal perichondrium (38%), or cartilage palisades (6%) are effective options 7
• Air-bone gap closed to within 10 dB in 92% of cases and within 20 dB in 100% of cases 7
• Novel adjuvant treatments include basic fibroblast growth factor (b-FGF) with gelatin sponge scaffold achieving 98.1% closure rate 1, 9

Safety of Bilateral Surgery

• Bilateral myringoplasty does not cause iatrogenic sensorineural hearing loss 7
• Hearing impairment during postoperative bilateral ear canal packing is surprisingly modest and acceptable to patients 7
• Mean follow-up at 13.8 months shows sustained perforation closure and hearing improvement 7

Red Flags Requiring Urgent ENT Referral

• Continuous pain, vertigo, or facial paralysis 3
• History of vertigo, nausea, and vomiting suggesting ossicular chain disruption 5
• Profound sensorineural loss signifying inner ear nerve damage 5
• Significant trauma requiring mastoid radiographs or CT scans 5
• Perforations that do not heal within 1 month of conservative management 3, 5

Critical Pitfalls to Avoid

• Never assume the tympanic membrane is intact if you cannot visualize it due to canal edema or debris—treat as if perforation is present and avoid ototoxic preparations 2
• Topical anesthetic drops (benzocaine/antipyrine) should not be used with perforations as they are not FDA-approved for middle ear use 2
• Prolonged topical antibiotic use (>10 days) increases risk of fungal superinfection (otomycosis) 2
• Do not delay ENT referral for bilateral perforations with hearing difficulty, as optimizing auditory access is critical for speech and language development in children 4