What is the treatment for a ruptured tympanic membrane?

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, while for clean perforations without infection, keep the ear dry and observe for spontaneous healing. 1, 2

Initial Assessment

• Confirm the diagnosis through careful otoscopic examination, documenting the size and location of the perforation 1
• Assess for modifying factors including diabetes, immunocompromised state, or signs of infection extending beyond the ear canal 1, 2
• Obtain audiometry if there is vertigo, nausea, or suspected conductive hearing loss >30 dB, as this suggests ossicular chain disruption 3
• Clean the ear canal by suctioning debris and discharge under microscopic guidance before any treatment 1, 2

Treatment Based on Clinical Presentation

For Perforations WITHOUT Active Infection (Clean, Asymptomatic)

• Keep the ear dry using ear plugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until healed 1, 2
• Most small perforations (especially <50% surface area) heal spontaneously within 4-8 weeks 4, 3
• Provide adequate analgesia: acetaminophen or NSAIDs for mild-moderate pain; oxycodone or hydrocodone combinations for moderate-severe pain 2
• Reassess if no healing occurs within one month to determine need for otolaryngology referral 3

For Perforations WITH Active Infection (Otorrhea, Inflammation)

Topical Antibiotic Therapy (Preferred)

• Use topical fluoroquinolone drops as first-line: ciprofloxacin-dexamethasone (combination preferred) or ofloxacin alone 1, 2
• Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics at the infection site 1, 2
• For ofloxacin dosing in perforated membranes (age ≥12 years): 10 drops (0.5 mL) into affected ear twice daily for 14 days 5
• Warm the bottle in hand for 1-2 minutes before instillation to avoid dizziness 5
• Have patient lie with affected ear upward, instill drops, pump tragus 4 times, and maintain position for 5 minutes 2, 5
• Limit treatment to a single course of no more than 10-14 days to prevent otomycosis from prolonged quinolone use 1, 2

Systemic Antibiotics (Reserved for Specific Indications Only)

• Add or switch to systemic antibiotics ONLY when: cellulitis of pinna/adjacent skin present, infection extends outside ear canal, diabetes or immunocompromised state, or topical therapy fails after 48-72 hours 1, 2
• First choice: amoxicillin for 5-7 days targeting S. pneumoniae, H. influenzae, and M. catarrhalis 2
• Second choice: amoxicillin-clavulanate for β-lactamase-producing organisms 2

Critical Medications and Interventions to AVOID

Never use the following in perforated tympanic membranes:

• Aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) cause severe permanent sensorineural hearing loss 1, 2
• Alcohol-containing drops cause pain and ototoxicity in the middle ear 1, 2
• Cerumenolytics, mineral oil, or any oil-based preparations 1, 2
• Ear canal irrigation—this can cause middle ear infection, vertigo, or ototoxicity 1, 2
• Cotton-tipped applicators that may cause further trauma or leave fibers 1, 2

Common Pitfalls and Warning Signs

• If the patient tastes ear drops, this confirms perforation—immediately switch to non-ototoxic fluoroquinolone preparation 1, 2
• Even when you cannot visualize the tympanic membrane due to canal edema or debris, assume perforation may be present and avoid aminoglycosides 1
• Patients with tympanostomy tubes should be treated as having non-intact tympanic membranes for at least 6-12 months after placement 1
• If no response within 48-72 hours, perform further aural debridement or culture persistent drainage (though quinolones typically succeed despite reported resistance due to high local concentrations) 1, 2

Surgical Referral Indications

• Traumatic perforations associated with vertigo or significant hearing loss (>30 dB conductive loss) 3
• Perforations that fail to heal spontaneously after one month 3
• Large perforations (>50% surface area or grade 4) that may require tympanoplasty 4, 6
• Chronic suppurative otitis media with persistent perforation 2

Special Population Considerations

• Children: All pediatric traumatic perforations in one series healed spontaneously without intervention 4
• Diabetic or immunocompromised patients: Have lower threshold for systemic antibiotics and consider atraumatic cleaning with aural suctioning under microscopic guidance 2