What is the treatment for a ruptured eardrum (tympanic membrane perforation)?

Treatment of Ruptured Eardrum (Tympanic Membrane Perforation)

Initial Management: Conservative Approach

Most traumatic tympanic membrane perforations heal spontaneously without intervention, with 95-99% closure rates under watchful waiting, making conservative management the first-line approach. 1, 2

Immediate Ear Protection Measures

• Keep the ear completely dry to prevent secondary infection—use earplugs or cotton balls coated with petroleum jelly when showering, and avoid swimming entirely until healing is confirmed. 1
• Avoid cotton-tipped applicators in the ear canal, as they may cause further trauma or leave behind fibers that impede healing. 1
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity. 1

When to Use Topical Antibiotics

If signs of infection develop (otorrhea, increased pain, canal inflammation), use topical fluoroquinolone antibiotics as first-line therapy—they are safe for middle ear exposure and achieve drug concentrations 100-1000 times higher than oral antibiotics. 1

Specific Antibiotic Selection

• Use only fluoroquinolone-based drops (ofloxacin or ciprofloxacin-dexamethasone)—these lack ototoxicity even with direct middle ear contact. 1
• Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—these cause severe permanent sensorineural hearing loss after exposure through perforations. 1
• Combination antibiotic-corticosteroid drops (fluoroquinolone + steroid) are superior to antibiotics alone for efficacy. 1

Application Technique

• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery. 1
• Have the patient lie with the affected ear up for 3-5 minutes after instillation, and "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

When to Add Systemic Antibiotics

Reserve oral antibiotics for specific high-risk situations only—topical therapy alone is superior for localized infection. 1

Add systemic antibiotics when:

• Cellulitis of the pinna or adjacent skin is present 1
• The patient has diabetes or is immunocompromised 1
• Signs of severe infection exist (fever, systemic symptoms) 1
• Topical therapy fails after 48-72 hours despite adequate drug delivery 1

Expected Timeline and Follow-Up

• Most traumatic perforations heal spontaneously within weeks to months under conservative management. 3, 2
• If the perforation persists beyond 6 months, surgical closure (myringoplasty/tympanoplasty) is warranted. 4
• Biannual follow-up for a minimum of 2 years is recommended, as any traumatic perforation carries risk of cholesteatoma formation. 4

Special Circumstances Requiring ENT Referral

Immediate ENT consultation is needed when:

• Continuous pain, vertigo, or facial paralysis exists 3
• Blast injury mechanism (higher risk of secondary cholesteatoma requiring surgical exploration) 2
• Suspected ossicular chain damage or perilymphatic fistula 4
• Immediate complete facial nerve paralysis 4
• Perforation from thermal or caustic injury (less likely to heal spontaneously) 4

Common Pitfalls to Avoid

• Never use alcohol-containing drops—alcohol in the middle ear space is both painful and potentially ototoxic. 1
• If a patient tastes ear drops, this indicates perforation and the drops should be discontinued immediately. 1
• Avoid cerumenolytics or irrigation when the tympanic membrane is not intact. 1
• Do not assume the tympanic membrane is intact if you cannot visualize it due to canal edema or debris—treat as if perforation is present and avoid ototoxic preparations. 1