What is the treatment for a patient with a broken tympanic membrane and bleeding from the ear, experiencing pain?

Treatment of Tympanic Membrane Perforation with Bleeding and Pain

For a patient with a broken tympanic membrane, bleeding from the ear, and pain, keep the ear dry, provide adequate analgesia with acetaminophen/NSAIDs for mild-moderate pain or opioid combinations for severe pain, use topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone) if infection is present, and avoid ear irrigation, ototoxic drops, and cotton-tipped applicators. 1

Immediate Management

Pain Control

• Provide adequate analgesia based on pain severity, as tympanic membrane perforation pain can be intense due to proximity of the periosteum 1
• Use acetaminophen or NSAIDs for mild to moderate pain 1
• Use combination products with oxycodone or hydrocodone for moderate to severe pain 1

Ear Protection - Critical First Step

• Keep the ear completely dry to prevent infection and allow spontaneous healing 1, 2
• Instruct the patient to use ear plugs or cotton balls coated with petroleum jelly when showering 2
• Avoid swimming until the perforation has healed 2
• Most small to moderate perforations (up to 93% in some series) heal spontaneously within 6-8 weeks with conservative management alone 3, 4, 5

Initial Assessment

• Carefully suction blood, purulent secretions, and debris from the canal under direct visualization 4
• Document perforation size and location - this affects prognosis 5
• Avoid irrigation and pneumatic otoscopy completely, as these can worsen injury, introduce infection, or cause vertigo 1, 2, 4

Antibiotic Therapy

When to Use Topical Antibiotics

• If signs of infection are present (purulent drainage, erythema, fever), use topical fluoroquinolone antibiotics 1, 2
• Topical therapy is superior to systemic antibiotics, delivering drug concentrations 100-1000 times higher at the infection site 2

Safe Topical Antibiotic Selection

• Use only fluoroquinolone-based drops (ofloxacin or ciprofloxacin-dexamethasone) - these are the ONLY safe topical antibiotics for perforated tympanic membranes 1, 2, 6
• For patients ≥12 years with perforation: ofloxacin 10 drops (0.5 mL) twice daily for 14 days 6
• Clean the ear canal by suctioning debris before administering drops to enhance drug delivery 2
• Have the patient lie with affected ear up for 5 minutes after instillation, and pump the tragus 4 times to facilitate middle ear penetration 2, 6
• Limit treatment to a single course of no more than 10-14 days to prevent otomycosis 2

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, 2
• Avoid alcohol-containing drops - alcohol in the middle ear space is both painful and potentially ototoxic 7, 2
• Do not use cerumenolytics or perform irrigation when the tympanic membrane is not intact 7, 2

When to Add Systemic Antibiotics

• Add systemic antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis if: 1, 2
  • Cellulitis of the pinna or adjacent skin is present
  • Signs of severe infection or systemic symptoms exist
  • Topical therapy fails after 48-72 hours despite adequate drug delivery
  • Patient has diabetes or is immunocompromised
• Use amoxicillin as first-line, or β-lactamase-stable agents given current resistance patterns 1

Common Pitfalls to Avoid

• Never irrigate the ear when perforation is present or suspected - this can cause middle ear infection, vertigo, or ototoxicity 7, 2, 4
• Do not use cotton-tipped applicators in the ear canal - they may cause further trauma or leave behind fibers 2
• If the patient tastes ear drops, this indicates perforation and the drops should be discontinued immediately 2
• Even when you cannot visualize the tympanic membrane due to canal edema or debris, assume a perforation may be present and avoid ototoxic preparations 2

Follow-Up and Referral Indications

• Reassess if patient fails to respond to initial therapy within 48-72 hours 2
• Refer to otolaryngology if: 4
  • History of vertigo, nausea, or vomiting (suggests ossicular chain disruption)
  • Conductive hearing loss >30 dB or profound sensorineural loss
  • Perforation does not heal within 1 month
  • Perforation from chronic otitis media
• Children have excellent prognosis - all pediatric cases in one series healed spontaneously 3
• Factors associated with poor healing include postero-superior location, large size (>2/3 of TM), and penetrating injuries 5