Treatment of Chronic Perforated Eardrum with Yellowish Drainage
The best treatment is topical ofloxacin ear drops, 10 drops twice daily for 14 days, which is specifically FDA-approved for chronic suppurative otitis media with perforated tympanic membranes and is non-ototoxic. 1
Initial Management Approach
Primary Treatment: Topical Quinolone Antibiotics
Topical quinolone antibiotics are the treatment of choice for chronic suppurative otitis media with drainage through a perforated eardrum, demonstrating superior efficacy compared to systemic antibiotics 2
Ofloxacin is the preferred agent because it is specifically non-ototoxic and safe for use with perforated tympanic membranes 3, 1
Dosing regimen: 10 drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for 14 days 1
Application technique: Warm the bottle in hand for 1-2 minutes, have patient lie with affected ear upward, instill drops, pump the tragus 4 times by pushing inward to facilitate penetration into the middle ear, maintain position for 5 minutes 1
Why Topical Quinolones Are Superior
Topical quinolones achieve 3.21 times better discharge resolution at 1-2 weeks compared to systemic non-quinolone antibiotics (RR 3.21,95% CI 1.88 to 5.49) 4
They also outperform systemic quinolones alone (RR 3.18,95% CI 1.87 to 5.43) 4
Oral antibiotics are unnecessary for most ear infections with perforations unless the patient is systemically ill 2
Essential Supportive Measures
Keep the Ear Dry
Maintaining a dry ear is critical to prevent ongoing infection and promote healing 5, 3, 6
Use cotton saturated with Vaseline to cover the ear opening during bathing or hair washing 2
Prohibit swimming until drainage completely stops 2
Ear Canal Cleaning
Remove drainage buildup with a cotton-tipped swab dipped in hydrogen peroxide or warm water, or gently suction with an infant nasal aspirator 2
Avoid ear irrigation and pneumatic otoscopy in confirmed or suspected perforations to prevent further damage 5, 3
Critical Safety Considerations
Ototoxicity Prevention
Only use non-ototoxic preparations when the tympanic membrane is not intact 5, 3
Aminoglycosides (gentamicin, neomycin, tobramycin) and chloramphenicol should be avoided due to ototoxicity risk through damaged auditory hair cells 7, 4
Do not use antibiotic eardrops for more than 10 days continuously to avoid yeast infections of the ear canal 2
When to Escalate Care
Indications for ENT Referral
Drainage persisting beyond 7 days of appropriate topical antibiotic treatment 2
Continuous pain, vertigo, or facial paralysis (alarming signs suggesting complications) 6
Hearing loss, continued ear infections, or persistent ear pain/discomfort 2
Re-evaluate if symptoms do not completely resolve after 2 weeks of treatment 5
Surgical Considerations for Non-Healing Perforations
Chronic perforations that fail to heal spontaneously may require surgical closure via myringoplasty or tympanoplasty 5, 8
Novel molecular treatments show promise: Basic fibroblast growth factor (b-FGF) with gelatin sponge scaffold has demonstrated closure rates up to 98.1% 5, 3, 9
The procedure involves freshening perforation edges to remove epithelialized tissue, then applying growth factors with appropriate scaffold material 5, 3
Common Pitfalls to Avoid
Do not prescribe oral antibiotics as first-line treatment - topical therapy is more effective and avoids systemic side effects 2, 4
Do not use aminoglycoside ear drops (gentamicin, neomycin) in perforated eardrums due to ototoxicity risk 7, 4
Do not assume the perforation will heal while active infection persists - treat the infection first, then allow time for spontaneous closure 5, 6
Avoid water exposure during active drainage, as this perpetuates infection and prevents healing 2, 5