What is the treatment for otitis media with a perforated tympanic membrane (eardrum)?

Treatment of Otitis Media with Tympanic Membrane Perforation

For acute otitis media with spontaneous tympanic membrane perforation, use topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin) rather than systemic antibiotics, as they deliver 100-1000 times higher drug concentrations at the infection site and avoid ototoxicity risk. 1

Initial Assessment and Diagnosis

Confirm the perforation through careful otoscopic examination, documenting the size and location of the defect 1. Assess for modifying factors that influence management:

• Diabetes or immunocompromised state 1
• Prior radiotherapy 2
• Concurrent middle ear disease 2
• Signs of infection extension beyond the ear canal 1

Distinguish between acute otitis media with perforation versus chronic suppurative otitis media (CSOM), as treatment approaches differ 2.

Medical Management

Topical Antibiotic Therapy (First-Line)

Topical fluoroquinolone antibiotics are superior to systemic antibiotics for otitis media with perforation because they achieve drug concentrations 100-1000 times higher than oral antibiotics at the infection site 1.

Recommended topical agents:

• Ciprofloxacin-dexamethasone drops 1
• Ofloxacin drops 1

These fluoroquinolones lack ototoxicity even with direct middle ear exposure 1.

Treatment protocol:

• Clean the ear canal first by suctioning debris and discharge to enhance drug delivery 1
• Administer drops after cleaning—blot the canal opening or use gentle suction to remove visible secretions 1
• Have the patient lie with affected ear up for 3-5 minutes after instillation 1
• "Pump" the tragus several times to facilitate middle ear penetration 1
• Limit treatment to a single course of no more than 10 days to prevent otomycosis 1

Evidence supporting topical over systemic therapy: Three studies comparing topical versus oral ciprofloxacin found topical administration increased resolution of ear discharge at 1-2 weeks (RR 1.48,95% CI 1.24-1.76) 3.

Systemic Antibiotics (Second-Line)

Reserve systemic antibiotics for specific situations only 1:

• Cellulitis of the pinna or adjacent skin
• Signs of severe infection or systemic involvement
• Topical therapy failure after 48-72 hours despite adequate drug delivery
• Patients with diabetes or immunocompromised state
• Extension of infection outside the ear canal

When systemic antibiotics are indicated:

• Amoxicillin is first-line for acute otitis media 2, 4, 5
• Amoxicillin-clavulanate for resistant cases or when beta-lactamase-producing bacteria are suspected 2

Pain Management

Assess pain severity and provide adequate analgesia, as pain from otitis media can be intense due to proximity of the periosteum to the ear canal 2.

• Mild to moderate pain: acetaminophen or NSAIDs 2
• Severe pain: combination with opioids (oxycodone or hydrocodone) 2
• NSAIDs during acute phase significantly reduce pain compared to placebo 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.

Avoid alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic 1.

Do not irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 1.

Ear Protection Measures

Keep the ear dry to prevent infection 1:

• Use ear plugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has healed 1

When to Reassess or Refer

Reassess within 48-72 hours if the patient fails to respond to initial therapy to confirm diagnosis and exclude other causes 1.

Consider otolaryngology referral for:

• Traumatic perforations associated with vertigo or significant hearing loss (>30 dB conductive loss suggests ossicular chain disruption) 6
• Perforations from chronic otitis media 6
• Perforations from acute otitis media that do not heal within one month 6
• Persistent drainage despite appropriate topical therapy 1

If topical therapy fails:

• Perform further aural debridement or suctioning 1
• Culture persistent drainage to detect pathogens like fungi or MRSA 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Surgical Considerations for Chronic Perforations

For chronic tympanic membrane perforations that fail to heal spontaneously:

Cartilage tympanoplasty provides better structural outcomes (fewer postoperative perforations) compared to temporalis muscle fascia, though hearing outcomes are similar 2.

Novel adjuvant therapies including gelatin sponge scaffolds soaked in fibroblast growth factor (b-FGF) achieved 98.1% closure rate versus 10% with saline in chronic perforations 2.