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 0.3% or ciprofloxacin-dexamethasone) as first-line therapy, and reserve systemic antibiotics (amoxicillin-clavulanate) only for cases with cellulitis, severe infection, or specific host factors like diabetes or immunocompromised state. 1

When Antibiotics Are Actually Needed

• Asymptomatic perforation without signs of infection does not require any antibiotics—management focuses solely on keeping the ear dry and protecting it from water exposure 1
• Antibiotics are indicated only when there is active infection with purulent discharge, not for the perforation itself 2
• For infected perforations, topical therapy achieves drug concentrations 100-1000 times higher than oral agents at the infection site, making it vastly superior to systemic antibiotics for localized infections 1, 3

First-Line Topical Therapy

• Ofloxacin 0.3% otic solution or ciprofloxacin-dexamethasone combination drops are the only safe topical antibiotics for perforated tympanic membranes 1, 3
• Fluoroquinolones are uniquely safe because they lack ototoxicity even with direct middle ear exposure through the perforation 1, 3
• Combination antibiotic-corticosteroid drops (ciprofloxacin-dexamethasone) are superior to antibiotics alone for clinical efficacy 3
• Clinical cure rates with ofloxacin range from 75-91% in chronic suppurative otitis media with perforated tympanic membranes 4

Critical Treatment Protocol

• Clean the ear canal first by suctioning debris and discharge before administering any drops—this is essential for drug delivery to the middle ear space 1, 3
• Have the patient lie with the affected ear up for 3-5 minutes after instillation 1, 3
• "Pump" the tragus several times to facilitate middle ear penetration 1, 3
• Limit treatment to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1, 3
• Only 4-8% of patients require oral antibiotic rescue therapy when topical fluoroquinolones are used properly 1, 3

When to Add Systemic Antibiotics

• Amoxicillin-clavulanate is the first-choice systemic antibiotic when oral therapy is needed, providing coverage for β-lactamase-producing organisms like H. influenzae and M. catarrhalis 1, 5
• Add systemic antibiotics only when: 1, 3
  • Cellulitis of the pinna or adjacent skin is present
  • Signs of severe infection exist (high fever, systemic illness)
  • Topical therapy fails after 48-72 hours despite adequate drug delivery
  • Patient has diabetes or is immunocompromised
• For children over 3 months with acute otitis media and perforation, the most frequent bacteria are S. pneumoniae, H. influenzae, and M. catarrhalis 6

Medications That Must Be Avoided

• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—these cause severe permanent sensorineural hearing loss after exposure through perforations 1, 3
• Avoid alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic 3
• Do not use cerumenolytics or irrigation when a perforation is present or suspected 1, 3
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 3

Common Pitfalls to Avoid

• If a patient tastes ear drops, this indicates a perforated eardrum—they should inform their doctor immediately, as this confirms middle ear access 3
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 3
• Do not prescribe antibiotics when you cannot visualize the tympanic membrane due to cerumen—clean the canal first or refer to ENT rather than treating blindly 6
• Assume tympanic membrane is non-intact in patients with tympanostomy tubes for at least 6-12 months after placement 3

Special Considerations for Acute Otitis Media with Perforation

• In children under 2 years with acute otitis media and perforation, antibiotic therapy is recommended (amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil) 6
• Treatment duration is 8-10 days for children below 2 years of age and 5 days for older children 6, 7
• Perforation of the tympanic membrane with purulent discharge indicates a bacterial cause requiring immediate antibiotic treatment 7