What antibiotics are recommended for a ruptured tympanic membrane (TM)?

Antibiotic Management for Ruptured Tympanic Membrane

For a ruptured tympanic membrane with infection, use topical fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) as first-line therapy, avoiding all aminoglycoside-containing preparations due to severe ototoxicity risk. 1

When Antibiotics Are Indicated

Asymptomatic perforation without infection does not require antibiotics - the primary management is keeping the ear dry and protecting it from water exposure. 1, 2

For infected perforations (otorrhea present), treatment depends on infection extent:

• Localized infection: Topical fluoroquinolone drops are superior to systemic antibiotics, achieving drug concentrations 100-1000 times higher than oral agents at the infection site. 1

• Systemic antibiotics are reserved for:

  • Extension of infection beyond the ear canal (cellulitis of pinna or adjacent skin) 1
  • Patients with diabetes or immunocompromised state 1
  • Failure of topical therapy after 48-72 hours despite adequate drug delivery 1
  • Signs of severe infection 1

Specific Antibiotic Recommendations

Topical Therapy (Preferred for Localized Infection)

First-line topical agents (both are safe with non-intact tympanic membranes):

• Ofloxacin 0.3% otic solution: 0.5 mL twice daily for 10-14 days 3, 4
• Ciprofloxacin-dexamethasone combination drops: The corticosteroid component provides superior efficacy compared to antibiotic alone 1

Critical safety point: Fluoroquinolones are the ONLY topical antibiotics safe for perforated tympanic membranes because they lack ototoxicity even with direct middle ear exposure. 1, 4

Systemic Therapy (When Required)

When systemic antibiotics are indicated, the causative pathogens are primarily H. influenzae (35.8%) and Staphylococcus aureus (26.4%) in perforations from acute otitis media. 5

Recommended systemic agents:

• Amoxicillin-clavulanate: First choice, provides coverage for β-lactamase-producing organisms (20-30% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase) 6, 5
• Alternative agents: Cefuroxime-axetil or cefpodoxime-proxetil 6

Critical Medications to AVOID

Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) - these cause severe permanent sensorineural hearing loss after exposure through perforations. 1 This is the most important safety consideration.

Also avoid:

• Alcohol-containing drops (painful and potentially ototoxic in middle ear space) 1
• Cerumenolytics or irrigation when perforation is present 1

Treatment Protocol for Topical Therapy

1. Clean the ear canal first by suctioning debris and discharge to enhance drug delivery to the middle ear space 1

2. Administer drops properly:

   • Have patient lie with affected ear up for 3-5 minutes after instillation 1
   • "Pump" the tragus several times to facilitate middle ear penetration 1

3. Limit treatment duration to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1

4. Reassess at 48-72 hours if no improvement - consider further aural debridement or culture persistent drainage (though quinolones typically succeed even with reported resistance due to high local concentrations) 1

Common Pitfalls to Avoid

• Do not irrigate the ear canal when perforation is present or suspected - this can cause middle ear infection, vertigo, or ototoxicity 1
• Do not use cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 1
• Do not assume topical therapy alone is adequate if cellulitis extends beyond the ear canal or patient has diabetes/immunocompromised state 1
• If patient tastes ear drops, this confirms perforation and warrants immediate reassessment of medication safety 1

Expected Outcomes

With appropriate fluoroquinolone therapy, clinical cure rates are:

• Chronic suppurative otitis media with perforation: 75-91% cure rate 3, 4
• Otitis externa: >80% cure rate in adults, >95% in children 4
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 1