What is the treatment for a ruptured tympanic membrane?

Management of Ruptured Tympanic Membrane

Immediate Ear Protection

Keep the ear completely dry to prevent infection—this is the single most important intervention for uncomplicated tympanic membrane perforations. 1

• Use ear plugs or cotton balls coated with petroleum jelly when showering 1
• Prohibit swimming until the perforation has completely healed 1, 2
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 3, 1

When to Use Antibiotics

Topical Antibiotics (Preferred for Infection)

If signs of infection are present (otorrhea, inflammation), use topical fluoroquinolone drops—they are safe for perforated eardrums and deliver 100-1000 times higher drug concentrations than oral antibiotics. 1

• First-line: Ofloxacin or ciprofloxacin-dexamethasone drops 1, 4

  • Ofloxacin dosing for perforated TM: 10 drops (0.5 mL) twice daily for 14 days in patients ≥12 years 5
  • Have patient lie with affected ear up for 5 minutes after instillation 5
  • Pump the tragus 4 times to facilitate middle ear penetration 1, 5

• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery 1

• Limit treatment to a single course of no more than 10-14 days to prevent otomycosis 1

Systemic Antibiotics (Limited Indications Only)

Add or switch to oral antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis only when: 1, 4

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection or extension beyond the ear canal exist
• Patient has diabetes or is immunocompromised
• Topical therapy fails after 48-72 hours despite adequate drug delivery

First-line systemic choice: Amoxicillin or β-lactamase-stable agents 4

Critical Medications to AVOID

Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations. 3, 1, 4

• Avoid alcohol-containing drops—alcohol in the middle ear is painful and ototoxic 1
• Do not use cerumenolytics or irrigation when the tympanic membrane is not intact 3
• Mineral oil is contraindicated in perforated eardrums 1

Pain Management

Provide adequate analgesia based on severity: 4

• Mild to moderate pain: Acetaminophen or NSAIDs
• Moderate to severe pain: Combination products with oxycodone or hydrocodone

Expected Healing Timeline

Most traumatic perforations heal spontaneously: 6, 7, 8

• 62% heal within 3 months 9
• 69% heal within 10 months 9
• All children in one study healed spontaneously without intervention 8

When to Refer to ENT

Refer for otolaryngology evaluation if: 6, 7

• Vertigo, nausea, or vomiting present (suggests ossicular chain disruption) 7
• Conductive hearing loss >30 dB (suggests ossicular damage) 7
• Profound sensorineural hearing loss (suggests inner ear nerve damage) 7
• Facial paralysis 6
• Perforation persists beyond 10 months 9
• Large central kidney-shaped perforations (least likely to heal spontaneously) 9

Surgical Options for Persistent Perforations

If perforation fails to heal after 10 months: 9

• Cartilage reconstruction provides superior structural outcomes compared to temporalis fascia 4
• Basic fibroblast growth factor (b-FGF) with gelatin sponge achieves 98.1% closure rate versus 10% with saline 4

Common Pitfalls

• If a patient tastes ear drops, this indicates perforation—stop the drops immediately and reassess 1
• Do not use cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 3, 1
• Avoid pneumatic otoscopy in suspected perforation cases 4, 7
• Even when you cannot visualize the tympanic membrane due to canal edema, assume perforation may be present and avoid ototoxic preparations 1