What is the management of tympanic membrane (TM) perforation in the emergency department (ED)?

Management of Tympanic Membrane Perforation in the Emergency Department

Keep the ear dry, avoid irrigation and pneumatic otoscopy, use only non-ototoxic topical antibiotics if infection is present, provide adequate analgesia, and allow spontaneous healing with ENT follow-up in 2-4 weeks. 1, 2, 3

Immediate Assessment and Precautions

What NOT to Do

• Avoid ear irrigation completely as this can introduce infection and worsen the injury 2, 3
• Avoid pneumatic otoscopy which can extend the perforation or cause further damage 2, 3
• Never use ototoxic ear drops (aminoglycosides, alcohol-based preparations) as these can cause permanent sensorineural hearing loss when the TM is not intact 4, 1, 2

Initial Examination

• Carefully suction blood, purulent secretions, and debris from the ear canal under direct visualization 3
• Document perforation size (as percentage of TM) and location (anterior/posterior, superior/inferior quadrants) 3, 5
• Assess for vertigo, nausea, or vomiting which suggest ossicular chain disruption 3
• Check for profound hearing loss which may indicate inner ear damage 3

Pain Management

Provide adequate analgesia based on pain severity, as TM perforation pain can be intense due to proximity of the periosteum. 4

• Mild to moderate pain: acetaminophen or NSAIDs (ibuprofen significantly reduces pain compared to placebo) 4
• Moderate to severe pain: combination products with oxycodone or hydrocodone 4
• Administer analgesics regularly rather than as-needed, as pain is easier to prevent than treat 4
• Consider parenteral analgesia in rare cases of severe pain requiring rapid relief 4

Antibiotic Therapy

When Antibiotics Are Indicated

• Perforations associated with acute otitis media require systemic antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis 4
• Chronic suppurative otitis media with perforation requires topical fluoroquinolones 6

Specific Antibiotic Recommendations

For chronic suppurative otitis media with TM perforation in patients ≥12 years: Ofloxacin otic 10 drops (0.5 mL) twice daily for 14 days 6

• Warm the bottle in hand for 1-2 minutes before instillation 6
• Patient lies with affected ear upward 6
• Pump tragus 4 times after instillation to facilitate middle ear penetration 6
• Maintain position for 5 minutes 6

For acute otitis media with systemic symptoms: Amoxicillin remains first-line, or use β-lactamase-stable agents (amoxicillin-clavulanate, second/third-generation cephalosporins) given current resistance patterns 4

Ear Care Instructions

The affected ear must be kept completely dry to prevent infection. 1, 2

• No swimming, showering without ear protection, or water exposure 1, 2
• Use cotton ball with petroleum jelly during bathing 3
• Avoid inserting anything into the ear canal 3

Expected Healing and Follow-Up

Spontaneous Healing Rates

• 89-93% of traumatic TM perforations heal spontaneously 7, 8
• All pediatric perforations in one series healed without surgery 7
• Average closure time: 22-27 days for small perforations 8

Factors Predicting Poor Healing

• Large perforations (>50% of TM surface) have only 54% healing rate vs 92% for small perforations 8
• Posterosuperior location associated with worse outcomes 5
• Penetrating injuries heal more poorly than blunt trauma 5
• Involvement of malleus/umbo prolongs healing time (42 vs 24 days) 8

Positive Prognostic Factors

• Wet perforations with bloody or watery discharge heal faster (improved rate and shortened time) 8
• Curled edges do NOT negatively affect healing 8

Follow-Up Strategy

Re-evaluate at 2 weeks if symptoms persist, with definitive assessment at 4-6 weeks. 1, 3

• Schedule ENT follow-up in 2-4 weeks for otoscopic re-examination 3
• Refer immediately to ENT if:
  • Vertigo or significant hearing loss present (suggests ossicular disruption) 3
  • Profound sensorineural hearing loss (suggests inner ear damage) 3
  • Perforation from chronic otitis media 3
  • No healing after 4-6 weeks of conservative management 3

Surgical Considerations

Perforations that fail to heal spontaneously after 1-2 months require ENT referral for possible tympanoplasty. 1, 2, 3

• Basic fibroblast growth factor (b-FGF) with gelatin sponge achieves 98.1% closure rate vs 10% with saline 1, 2
• Cartilage reconstruction provides superior structural outcomes compared to fascia grafts 2
• Various bioengineered scaffolds are safe and improve healing rates 2

Common Pitfalls to Avoid

• Using aminoglycoside ear drops (gentamicin, neomycin) which cause irreversible ototoxicity with non-intact TM 4, 1, 2
• Inadequate pain control - TM perforation pain is often underestimated and undertreated 4
• Premature irrigation attempting to "clean" the ear, which introduces infection 2, 3
• Failure to document perforation characteristics needed for prognostication and follow-up 3, 5