What is the best treatment approach for a patient with a sinus infection and a perforated right tympanic membrane (TM) with ear drainage?

Treatment of Sinus Infection with Perforated Tympanic Membrane and Ear Drainage

Treat this patient with topical non-ototoxic antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) for the ear drainage, combined with systemic antibiotics targeting the sinus infection, while keeping the ear dry. 1, 2

Immediate Management of the Perforated Tympanic Membrane

Topical Antibiotic Therapy

• Use only non-ototoxic topical preparations such as ofloxacin 0.3% or ciprofloxacin-dexamethasone drops, as ototoxic preparations (particularly aminoglycosides) can cause permanent sensorineural hearing loss when the tympanic membrane is not intact 1, 2
• Administer drops twice daily for up to 10 days maximum 1
• Instruct the patient to "pump" the tragus (flap of skin in front of the ear canal) several times after instilling drops to help medication reach the middle ear space 1
• Clean any visible drainage from the ear canal opening using a cotton-tipped swab dipped in hydrogen peroxide or warm water before administering drops 1

Critical Precautions

• Keep the ear completely dry to prevent infection and allow spontaneous healing 2, 3
• Avoid ear irrigation entirely, as this can introduce infection and worsen complications 2
• Prevent water entry during bathing by using cotton saturated with Vaseline to cover the ear canal opening 1
• Do not use pneumatic otoscopy, as this can worsen the perforation 2

Systemic Antibiotic Treatment for Sinus Infection

First-Line Therapy

For the acute bacterial rhinosinusitis component, prescribe based on disease severity and recent antibiotic exposure:

If no antibiotics in past 4-6 weeks (mild disease):

• High-dose amoxicillin/clavulanate (1.75-4 g/250 mg per day) is preferred 1
• Alternative: amoxicillin (1.5-4 g/day), cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1

If recent antibiotic use OR moderate disease:

• Respiratory fluoroquinolone (levofloxacin, moxifloxacin) OR high-dose amoxicillin/clavulanate (4 g/250 mg per day) 1
• These agents provide coverage against drug-resistant S. pneumoniae, H. influenzae, and M. catarrhalis 2, 4

When to Add or Switch to Systemic Antibiotics for the Ear

While topical therapy is first-line for the perforated TM with drainage, add or switch to systemic antibiotics if: 1

• Cellulitis of the pinna or adjacent skin develops
• Signs of severe infection exist (high fever, severe otalgia, toxic appearance)
• Ear drainage persists or worsens despite 72 hours of topical therapy
• The patient is immunocompromised or diabetic

Choose an oral antibiotic covering Pseudomonas aeruginosa and Staphylococcus aureus for ear-related systemic therapy, as these are the predominant pathogens in ear drainage through perforations 1, 5

Pain Management

• Provide adequate analgesia based on pain severity, as tympanic membrane perforation can cause intense pain 2
• Use acetaminophen or NSAIDs for mild to moderate pain 2
• Consider combination products with oxycodone or hydrocodone for moderate to severe pain 2

Follow-Up and Reassessment

Early Reassessment (48-72 hours)

• Ear drainage should show improvement within 48-72 hours of topical therapy 1
• Sinus symptoms should improve within 72 hours of systemic antibiotic therapy 1
• If no improvement occurs, reassess for: 1
  • Obstructing debris in the ear canal preventing drop delivery
  • Poor adherence to therapy
  • Need for culture to identify resistant organisms (MRSA, fungi, Pseudomonas)
  • Alternative diagnosis

Longer-Term Follow-Up

• Most traumatic perforations heal spontaneously within 6-8 weeks if kept dry and infection-free 3, 6
• Complete symptom resolution may take up to 2 weeks 1
• Refer to ENT if: 3
  • Perforation persists beyond 2-3 months
  • Continuous pain, vertigo, or facial paralysis develops
  • Ear drainage continues beyond 7 days despite appropriate therapy 1
  • Hearing loss persists after infection resolves

Common Pitfalls to Avoid

• Never use aminoglycoside-containing ear drops (commonly used for otitis externa) when a perforation is present or suspected, as these cause ototoxicity 1, 2
• Do not prescribe oral antibiotics alone for the ear drainage without topical therapy, as topical drops achieve 1000-fold higher concentrations at the infection site 1
• Avoid prolonged topical antibiotic use (>10 days) as this can induce fungal otitis externa (otomycosis) 1
• Do not allow water exposure to the affected ear during active infection or until perforation heals 1, 2