Should oral and otic (ear drop) antibiotics be used to treat a perforated eardrum?

Treatment of Perforated Eardrum with Antibiotics

For a perforated eardrum with infection, use topical non-ototoxic antibiotics (fluoroquinolone ear drops) as first-line treatment, NOT oral antibiotics, unless there is extension of infection beyond the ear canal or specific high-risk factors. 1

Critical First Step: Confirm Tympanic Membrane Status

• Always verify whether the tympanic membrane is perforated before prescribing any ear drops, as this fundamentally changes which topical preparations are safe to use 1
• If you taste the ear drops after administration, this confirms a perforation is present 1
• History of prior ear surgery, tympanostomy tubes, or barotrauma should raise suspicion for non-intact eardrum 1

Recommended Treatment Algorithm

For Perforated Tympanic Membrane WITH Infection:

Topical Therapy (First-Line):

• Prescribe ONLY non-ototoxic fluoroquinolone ear drops such as ofloxacin 0.3% or ciprofloxacin 1, 2, 3
• These achieve drug concentrations 100-1000 times higher than systemic antibiotics at the infection site 1
• Never use aminoglycoside-containing drops (neomycin/polymyxin B) in perforated eardrums due to ototoxicity risk 1

Dosing specifics for ofloxacin 0.3%:

• Adults and children ≥12 years with middle ear infection: 10 drops twice daily 3
• Children 1-12 years with middle ear infection: 5 drops twice daily 3
• Continue for at least 7 days even if symptoms improve 1

When to ADD Oral Antibiotics:

Reserve systemic antibiotics for specific circumstances ONLY: 1, 2

• Infection extends beyond the ear canal (cellulitis, mastoiditis)
• Immunocompromised patients or diabetes mellitus
• Topical drops cannot reach the infected area due to canal obstruction
• Treatment failure after 48-72 hours of appropriate topical therapy

If oral antibiotics are indicated:

• Use fluoroquinolones (e.g., ciprofloxacin) for coverage against Pseudomonas aeruginosa and Staphylococcus aureus, which cause 98% of cases 2
• Most commonly prescribed oral antibiotics (amoxicillin, amoxicillin-clavulanate) are inactive against Pseudomonas, the primary pathogen 2

Pain Management is Essential

• Assess pain severity at initial presentation using validated scales 1
• Prescribe analgesics based on intensity: acetaminophen or NSAIDs for mild-moderate pain; consider opioids for severe pain in first 48-72 hours 1, 2
• NSAIDs significantly reduce pain compared to placebo during acute phase 1
• Pain should improve within 48-72 hours of starting appropriate topical therapy 1

Evidence Supporting Topical Over Oral Antibiotics

Topical quinolones demonstrate superior outcomes: 4

• Clinical cure rates: 77-96% with topical vs 30-67% with oral antibiotics
• Relative risk of 3.21 (95% CI 1.88-5.49) favoring topical quinolones over systemic non-quinolones at 1-2 weeks 4
• Better bacterial eradication and patient satisfaction 2

Oral antibiotics have significant limitations: 1

• No significant difference in cure rates when added to topical therapy
• Cause systemic adverse effects: rashes, vomiting, diarrhea, allergic reactions (RR 1.3, NNT to harm = 14) 1
• Promote bacterial resistance and alter nasopharyngeal flora 1
• 20-40% of patients inappropriately receive oral antibiotics for conditions where topical therapy alone is sufficient 2

Proper Administration Technique

Instruct patients on correct ear drop application: 1

• Lie on side with affected ear up
• Fill ear canal completely with drops
• Remain on side for 5 minutes after administration
• Gently press tragus 4 times in pumping motion to facilitate middle ear penetration through perforation 3
• Avoid inserting cotton swabs or other objects into ear canal 2

Expected Clinical Course and Follow-Up

• Symptoms should improve within 48-72 hours of starting appropriate therapy 1, 2
• Most patients have minimal or no symptoms by 7 days 1
• If no improvement at 48-72 hours, reassess for: 2
  • Inadequate drug delivery (canal obstruction requiring aural toilet or wick placement)
  • Poor adherence to therapy
  • Fungal co-infection (especially in diabetics or treatment failures)
  • Allergic contact dermatitis from topical agents
  • Incorrect diagnosis

Common Pitfalls to Avoid

• Using ototoxic preparations (aminoglycosides like neomycin) when tympanic membrane integrity is compromised 1, 2
• Overprescribing oral antibiotics for uncomplicated cases that respond to topical therapy alone 1, 2
• Inadequate pain management in the first 48-72 hours before topical therapy takes effect 1, 2
• Missing fungal infections, particularly in diabetic patients or those failing antibacterial therapy 1, 2
• Selecting oral antibiotics with inadequate Pseudomonas coverage (most oral agents prescribed are inactive against this primary pathogen) 2

Special Populations Requiring Modified Approach

Diabetic patients: 2

• Higher risk for otomycosis and necrotizing otitis externa
• May require systemic antibiotics due to complication risk
• Monitor more carefully for treatment failure

Immunocompromised patients: 2

• Consider systemic antibiotics in addition to topical therapy
• Lower threshold for ENT referral