Treatment of Ruptured Eardrum
For a ruptured eardrum, keep the ear dry and use topical fluoroquinolone antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) if infection is present, while avoiding all aminoglycoside-containing drops and ear irrigation. 1
Initial Assessment
Confirm the diagnosis through careful otoscopic examination, documenting the size and location of the perforation. 1 Check for modifying factors including diabetes, immunocompromised status, or concurrent infections that may alter your management approach. 1
Most traumatic perforations (95%) heal spontaneously within weeks to months under watchful waiting, particularly when they are small (Griffin grade I). 2 However, blast injuries carry higher risk of cholesteatoma formation and may require surgical exploration. 2, 3
Ear Protection (Critical for All Patients)
Keep the ear completely dry to prevent infection. 1 Instruct patients to:
- Use ear plugs or cotton balls coated with petroleum jelly when showering 1
- Avoid swimming until the perforation has healed 1
- Never irrigate the ear canal, as this can cause middle ear infection, vertigo, or ototoxicity 1
Topical Antibiotic Therapy (When Infection Present)
Use only fluoroquinolone-based drops (ofloxacin or ciprofloxacin-dexamethasone) as first-line therapy for infected perforations. 1 These are the only safe topical antibiotics for non-intact tympanic membranes because they lack ototoxicity even with direct middle ear exposure. 1
Treatment Protocol:
- Clean the ear canal first by suctioning debris and discharge before administering drops 1
- Have the patient lie with affected ear up for 3-5 minutes after instillation 1
- "Pump" the tragus several times to facilitate middle ear penetration 1
- Limit treatment to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1
Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics can achieve, making it far superior for localized infections. 1
Critical Medications to AVOID
Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin) as they cause severe permanent hearing loss after administration through perforations. 1 Even a single course carries risk, and prolonged or repetitive use is particularly dangerous. 1
Additional contraindications:
When you cannot visualize the tympanic membrane due to canal edema or debris, assume a perforation may be present and avoid neomycin. 1
Systemic Antibiotics (Limited Indications Only)
Reserve oral antibiotics for specific situations only, as they are inferior to topical therapy for localized infection: 1
- Cellulitis of the pinna or adjacent skin 1
- Extension of infection outside the ear canal 1
- Diabetes or immunocompromised state 1
- Topical therapy failure after 48-72 hours despite adequate drug delivery 1
Only 4-8% of patients require oral antibiotic rescue therapy. 1
When to Reassess or Refer
Reassess if the patient fails to respond to initial therapy within 48-72 hours to confirm diagnosis and exclude other causes. 1 Consider:
- Further aural debridement or suctioning 1
- Culture persistent drainage to detect fungi or MRSA (though quinolones typically succeed despite reported resistance due to high local concentrations) 1
Refer to ENT for:
- Perforations persisting beyond 3-6 months 4, 5
- Blast injuries (higher cholesteatoma risk) 2, 3
- Vertigo, facial paralysis, or profound sensorineural hearing loss suggesting ossicular chain disruption or inner ear damage 5, 3
- Conductive hearing loss >30 dB 5
Common Pitfalls
- Never use cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind cotton fibers 1
- Do not perform pneumatic otoscopy with a perforation 5
- Patients with tympanostomy tubes should be treated as having non-intact tympanic membranes—assume tubes are patent for at least 6-12 months after placement 1
- Biannual follow-up for minimum of two years is recommended due to cholesteatoma risk 3