What ear drops are recommended for a perforated eardrum (tympanic membrane perforation) with drainage?

Recommended Ear Drops for Perforated Eardrum with Drainage

For a perforated tympanic membrane with drainage, use ofloxacin otic drops (10 drops twice daily for 14 days in patients ≥12 years) as the first-line treatment, avoiding aminoglycoside-containing drops due to ototoxicity risk. 1

First-Line Treatment: Ofloxacin

• Ofloxacin is specifically FDA-approved for chronic suppurative otitis media with perforated tympanic membranes, making it the safest and most appropriate choice 1
• The dosing for perforated eardrums is 10 drops (0.5 mL) instilled into the affected ear twice daily for 14 days in patients 12 years and older 1
• Warm the bottle in your hand for 1-2 minutes before instillation to avoid dizziness from cold solution 1
• Have the patient lie with the affected ear upward, instill drops, then pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear 1
• Maintain this position for 5 minutes after instillation 1

Alternative Option: Ciprofloxacin-Dexamethasone

• Ciprofloxacin-dexamethasone is also approved for use with perforated tympanic membranes, though it may delay healing more than ofloxacin alone 2, 3
• Research demonstrates that ciprofloxacin + dexamethasone significantly delays tympanic membrane healing compared to ofloxacin, with some perforations remaining unhealed at 40 days 3
• The steroid component (dexamethasone) potentiates the healing delay caused by ciprofloxacin 3
• Despite this concern, ciprofloxacin-dexamethasone remains an acceptable option when inflammation is prominent, as it was compared favorably in randomized trials for acute otorrhea through tympanostomy tubes 2

Critical Contraindications: Avoid Aminoglycosides

• Never use aminoglycoside-containing drops (neomycin-polymyxin B-hydrocortisone) with a perforated eardrum due to ototoxicity risk 4
• ENT-UK consensus guidelines state that if aminoglycosides are used with perforation, they should only be used for obvious infection, for no longer than 2 weeks, with baseline audiometry if possible 4
• Neomycin significantly delays tympanic membrane healing (up to day 28) compared to ofloxacin 3
• The risk of permanent sensorineural hearing loss from aminoglycoside exposure to the middle ear makes these drops inappropriate first-line agents 4

Duration and Monitoring

• Use ear drops for the full prescribed duration (14 days for perforated membranes) even if symptoms improve sooner to prevent relapse 5
• Most patients should experience improvement within 48-72 hours and minimal symptoms by 7 days 2
• If symptoms persist beyond 7 days, continue drops and notify the physician, with maximum treatment up to 7 additional days 2

Adjunctive Measures

• Clean visible drainage at the ear canal opening using a cotton-tipped swab dipped in hydrogen peroxide or warm water before instilling drops 2
• Alternatively, use tissue spears (twisted tissue paper) to absorb drainage from the canal opening 2
• Keep the ear dry by covering the ear canal opening with cotton saturated with petroleum jelly during bathing or hair washing 2
• Avoid swimming until drainage stops completely 2

Pain Management

• Use oral analgesics (acetaminophen or ibuprofen) at fixed intervals rather than as-needed for better pain control during the first 48-72 hours 6
• NSAIDs are particularly effective during acute inflammation 6
• Topical anesthetic ear drops are not recommended during active infection 2

Common Pitfalls to Avoid

• Do not use oral antibiotics alone—topical antibiotic drops are the most effective treatment for drainage through a perforation 2
• Oral antibiotics are unnecessary unless the patient is systemically ill, has another indication, or infection fails to resolve with topical therapy 2
• Never irrigate the ear or perform pneumatic otoscopy with a known perforation 7
• Avoid inserting cotton-tipped swabs or other objects into the ear canal beyond the opening 2, 6
• Do not use ear drops for longer than 10 days continuously to avoid yeast infections of the ear canal 2

When to Refer or Escalate

• Refer to otolaryngology if drainage persists beyond 2-3 weeks of appropriate topical therapy 2
• Immediate referral is warranted for vertigo, profound hearing loss (>30 dB conductive loss suggesting ossicular disruption), or signs of inner ear involvement 7
• Perforations that do not heal within one month require otolaryngologic evaluation 7