What medications and dosages are recommended for managing a perforated tympanic membrane?

Management of Perforated Tympanic Membrane

For perforated tympanic membranes with infection, use topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone) as first-line treatment, avoiding all aminoglycoside-containing drops which cause permanent hearing loss. 1, 2

Medication Selection and Dosing

Topical Fluoroquinolone Antibiotics (First-Line)

Topical therapy is strongly preferred over systemic antibiotics because it delivers drug concentrations 100-1000 times higher at the infection site. 1, 2

Ofloxacin Otic Solution

• For chronic suppurative otitis media with perforation (age ≥12 years): 10 drops (0.5 mL, 1.5 mg ofloxacin) into affected ear twice daily for 14 days 3
• For acute otitis media with tympanostomy tubes (ages 1-12 years): 5 drops (0.25 mL, 0.75 mg ofloxacin) twice daily for 10 days 3
• Warm bottle in hand 1-2 minutes before instillation to prevent dizziness 3
• Patient lies with affected ear upward, pump tragus 4 times after instillation, maintain position for 5 minutes 3

Ciprofloxacin-Dexamethasone Combination

• Combination antibiotic-corticosteroid drops are superior to antibiotics alone for efficacy 1
• Limit treatment to single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1, 2

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. 1, 2

Additional contraindications:

• Avoid alcohol-containing drops (painful and ototoxic in middle ear) 1
• Avoid cerumenolytics or irrigation when tympanic membrane is not intact 2
• Avoid mineral oil (oil-based preparations contraindicated with perforation) 1

Systemic Antibiotics (Second-Line)

Reserve systemic antibiotics only for specific indications—they are inferior to topical therapy for localized infection. 1, 2

Indications for Systemic Antibiotics

• Cellulitis of pinna or adjacent skin 2
• Extension of infection outside ear canal 1
• Diabetes or immunocompromised state 1, 2
• Topical therapy failure after 48-72 hours despite adequate drug delivery 2
• Signs of severe infection or systemic involvement 2

Systemic Antibiotic Selection

• First choice: Amoxicillin targeting S. pneumoniae, H. influenzae, and M. catarrhalis 2
• Second choice: Amoxicillin-clavulanate for β-lactamase-producing organisms 4, 2
• Duration: 5-7 days for acute otitis media 4

Treatment Protocol

Pre-Treatment Preparation

1. Clean ear canal first by suctioning debris and discharge under microscopic guidance to enhance drug delivery 1, 2
2. Use tissue spears to absorb secretions and facilitate entry of topical drops 1
3. For significant canal edema, place compressed cellulose wick moistened with aqueous solution before medication application 1

Administration Technique

• Warm drops by holding bottle in hand 1-2 minutes 3
• Patient lies with affected ear upward 3
• Instill prescribed number of drops 3
• Pump tragus 4 times by pushing inward to facilitate middle ear penetration 3
• Maintain position for 5 minutes 3

Follow-Up Management

• If no response within 48-72 hours: Reassess diagnosis, perform further aural debridement, or culture persistent drainage 1
• Culture may detect fungi or MRSA, though quinolones typically succeed despite reported resistance due to high local concentrations 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Ear Protection Measures

Keep ear dry to prevent infection—use ear plugs or cotton balls coated with petroleum jelly when showering, avoid swimming until healed. 1, 2

Additional precautions:

• Avoid cotton-tipped applicators (cause further trauma or leave fibers) 1, 2
• Never irrigate ear canal when perforation present or suspected (causes middle ear infection, vertigo, or ototoxicity) 1, 2
• Avoid pneumatic otoscopy with suspected perforation 2, 5

Pain Management

Provide adequate analgesia as perforation pain can be intense due to periosteum proximity. 2

• Mild to moderate pain: Acetaminophen or NSAIDs 2
• Moderate to severe pain: Combination products with oxycodone or hydrocodone 2

Special Populations

Children Under 2 Years with Bilateral AOM

• Antibiotics most beneficial in this subgroup (reduced pain at 2-7 days, fewer perforations) 4, 6
• Number needed to treat: 20 for pain reduction, 33 for preventing perforation 4, 6

Diabetic or Immunocompromised Patients

• Lower threshold for systemic antibiotics 1, 2
• Consider atraumatic cleaning with aural suctioning under microscopic guidance 2

Fungal Otomycosis with Perforation

• Topical antifungal therapy recommended 2
• Oral antifungals (itraconazole, voriconazole, or posaconazole) for refractory cases 4

Common Pitfalls

If patient tastes ear drops, this indicates perforation—inform physician immediately and switch to non-ototoxic preparation. 1

• Even when tympanic membrane not visualized due to canal edema or debris, assume perforation may be present and avoid aminoglycosides 1
• Patients with tympanostomy tubes should be treated as having non-intact membranes (assume tubes patent for 6-12 months after placement) 1
• Most small traumatic perforations (85.7-100%) resolve spontaneously without intervention, particularly in children 5, 7, 8