What is the management for a bloody tympanic membrane after trauma?

Management of Bloody Tympanic Membrane After Trauma

For a bloody tympanic membrane after trauma, keep the ear dry, avoid irrigation and ototoxic drops, and use topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin) only if signs of infection develop—most traumatic perforations heal spontaneously within 3-4 weeks without intervention. 1, 2, 3

Initial Assessment

Confirm the perforation through careful otoscopic examination, documenting the size, location, and presence of blood or discharge. 1 Avoid pneumatic otoscopy and irrigation, as these can worsen the injury, introduce infection, or cause vertigo and ototoxicity. 1, 4, 3

Assess for complications that require urgent otolaryngology referral:

• Vertigo, nausea, or vomiting suggesting ossicular chain disruption 3
• Conductive hearing loss >30 dB indicating possible ossicular damage 3
• Profound sensorineural hearing loss signifying inner ear nerve damage 3
• Basilar skull fracture or cranial vault fracture (strongly associated with tympanic membrane rupture) 5

Immediate Management

Keep the ear completely dry to prevent infection. 1, 4 Instruct patients to:

• Use earplugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has healed 1
• Avoid inserting cotton-tipped applicators, which can cause further trauma 1

Carefully suction blood, purulent secretions, and debris from the ear canal under direct visualization if present. 3 This atraumatic cleaning is particularly important for diabetic or immunocompromised patients. 4

Antibiotic Therapy

Do NOT routinely prescribe antibiotics for clean traumatic perforations. 2, 3 Most heal spontaneously without antimicrobial therapy.

Use topical fluoroquinolone antibiotics ONLY if infection develops:

• Ofloxacin or ciprofloxacin-dexamethasone drops are the only safe options for perforated tympanic membranes 1, 6, 4
• These achieve drug concentrations 100-1000 times higher than oral antibiotics at the infection site 4
• Limit treatment to a single 10-day course to prevent otomycosis 1, 4
• Clean the ear canal by suctioning before administering drops 1, 4
• Have the patient lie with the affected ear up for 3-5 minutes after instillation and pump the tragus several times 4

NEVER use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations), as they cause severe permanent sensorineural hearing loss after exposure through perforations. 1, 4

Add systemic antibiotics only when:

• Cellulitis of the pinna or adjacent skin is present 4
• Signs of severe infection develop 4
• Topical therapy fails after 48-72 hours 4
• The patient is diabetic or immunocompromised 4
• The perforation is associated with acute otitis media requiring coverage of S. pneumoniae, H. influenzae, and M. catarrhalis 4

Pain Management

Provide adequate analgesia based on pain severity, as tympanic membrane perforation pain can be intense. 4 Use acetaminophen or NSAIDs for mild to moderate pain, and combination products with oxycodone or hydrocodone for moderate to severe pain. 4

Expected Outcomes and Follow-Up

89-93% of traumatic perforations heal spontaneously within an average of 27 days (range 3-8 weeks). 2, 7, 8 All children in one series healed spontaneously without intervention. 2

Factors associated with faster healing:

• Wet perforations with bloody or watery discharge heal faster (mean 22-24 days) compared to dry perforations 8
• Small perforations (<33% of TM surface) heal in 92% of cases with average closure time of 23 days 8

Factors associated with delayed healing or poor outcomes:

• Large perforations (>33% of TM surface) have only 54% spontaneous healing rate and take 47 days on average 7, 8
• Postero-superior location is associated with poor healing 7
• Penetrating injuries have worse outcomes than blunt trauma 7
• Malleus or umbo damage prolongs closure time to 42 days (though healing rate remains similar) 8

Refer to otolaryngology if:

• Perforation fails to heal within 1 month 3
• Associated vertigo or significant hearing loss is present 3
• Large perforation (>50% of TM) or postero-superior location 7
• Penetrating injury mechanism 7

Critical Pitfalls to Avoid

Never irrigate the ear canal when perforation is present or suspected—this can cause middle ear infection, vertigo, or ototoxicity. 1, 4

Never use alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic. 1

If the patient tastes ear drops, this confirms perforation and the drops should be discontinued immediately. 1

Assume the tympanic membrane is perforated if you cannot visualize it due to canal edema or debris, and use only non-ototoxic preparations. 1