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

Treatment of Ruptured Tympanic Membrane

For a ruptured tympanic membrane with infection, use topical fluoroquinolone antibiotic drops (ciprofloxacin-dexamethasone or ofloxacin) as first-line treatment, never aminoglycoside-containing drops, and keep the ear dry. 1, 2

Initial Assessment

• Confirm the diagnosis with careful otoscopic examination, documenting perforation size and location 1
• Assess for modifying factors including diabetes, immunocompromised state, or signs of infection extension beyond the ear canal 1, 2
• Check for alarming features requiring urgent ENT referral: persistent pain, vertigo, facial paralysis, or profound sensorineural hearing loss suggesting ossicular chain disruption or inner ear damage 3, 4

Immediate Management: Ear Protection

• Keep the ear completely dry to prevent infection 1, 2
• Use ear plugs or cotton balls coated with petroleum jelly when showering 1, 2
• Avoid swimming until the perforation has healed 1, 2
• Never irrigate the ear canal when perforation is present or suspected, as this causes middle ear infection, vertigo, or ototoxicity 1, 2

Topical Antibiotic Therapy (If Infection Present)

Medication Selection:

• Use fluoroquinolone-based drops only: ciprofloxacin-dexamethasone or ofloxacin 1, 2
• Combination antibiotic-corticosteroid drops are superior to antibiotics alone 1, 2
• Topical therapy delivers drug concentrations 100-1000 times higher than oral antibiotics at the infection site 5, 1, 2

Critical Contraindications:

• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—these cause severe permanent sensorineural hearing loss 1, 2
• Avoid alcohol-containing drops (painful and ototoxic in middle ear) 1, 2
• Avoid cerumenolytics and mineral oil 1, 2

Treatment Protocol:

• Clean the ear canal first by suctioning debris and discharge under microscopic guidance 1, 2
• Use tissue spears to absorb secretions before drop application 5, 1, 2
• For significant canal edema, place a compressed cellulose wick moistened with aqueous solution to facilitate drug delivery 1, 2
• Have patient lie with affected ear up for 3-5 minutes after instillation and "pump" the tragus several times 1
• Limit treatment to a single course of no more than 10 days to prevent otomycosis 1, 2

Systemic Antibiotics (Reserved for Specific Indications Only)

Add or switch to oral antibiotics only when: 1, 2

• Cellulitis of pinna or adjacent skin is present
• Extension of infection outside the ear canal
• Diabetes or immunocompromised state
• Topical therapy fails after 48-72 hours despite adequate drug delivery

Antibiotic Selection:

• First choice: Amoxicillin (targets S. pneumoniae, H. influenzae, M. catarrhalis) 2
• Second choice: Amoxicillin-clavulanate for β-lactamase-producing organisms 2
• Duration: 5-7 days 2

Pain Management

• Provide adequate analgesia as perforation pain can be intense 2
• Mild to moderate pain: acetaminophen or NSAIDs 2
• Moderate to severe pain: combination products with oxycodone or hydrocodone 2

Follow-Up and Reassessment

• If no response within 48-72 hours, reassess diagnosis and exclude other causes 1, 2
• Perform further aural debridement or culture persistent drainage 1, 2
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 5, 1
• Most traumatic perforations heal spontaneously within 4-12 weeks, with 94% healing rate 6, 7

Special Populations

• Children: All pediatric traumatic perforations in one study healed spontaneously without surgery 6
• Diabetic/immunocompromised patients: Lower threshold for systemic antibiotics and consider atraumatic cleaning with aural suctioning under microscopic guidance 2

Critical Pitfalls to Avoid

• If patient tastes ear drops, this indicates perforation—switch immediately to non-ototoxic preparation 1, 2
• Never use cotton-tipped applicators in the ear canal (cause further trauma or leave fibers) 5, 1, 2
• Even when tympanic membrane cannot be visualized due to canal edema or debris, assume perforation may be present and avoid aminoglycosides 1, 2
• Avoid pneumatic otoscopy when perforation suspected 4

When to Refer to ENT

• Perforation persists beyond 1 month 4
• Traumatic perforations associated with vertigo or significant hearing loss (>30 dB conductive loss suggests ossicular chain disruption) 4
• Chronic suppurative otitis media or cholesteatoma 3
• Perforations that fail conservative management 3, 4