What is the recommended management, including medication dose and duration, for a perforated tympanic membrane?

Management of Perforated Tympanic Membrane

Topical Antibiotic Therapy (First-Line for Infected Perforations)

For perforated tympanic membranes with infection, use topical fluoroquinolone antibiotics exclusively—specifically ofloxacin or ciprofloxacin-dexamethasone—as they are the only non-ototoxic options safe for middle ear exposure. 1, 2

Specific Dosing Regimens

Ofloxacin otic solution:

• Chronic suppurative otitis media with perforation (age ≥12 years): 10 drops (0.5 mL, 1.5 mg) into affected ear twice daily for 14 days 3
• Acute otitis media with tympanostomy tubes (ages 1-12 years): 5 drops (0.25 mL, 0.75 mg) into affected ear twice daily for 10 days 3

Ciprofloxacin-dexamethasone combination: Preferred over antibiotics alone due to superior efficacy, with treatment limited to no more than 10 days to prevent otomycosis 1, 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, 2 This applies even when you cannot visualize the tympanic membrane due to canal edema or debris—assume perforation may be present 1.

Additional contraindications include alcohol-containing drops, cerumenolytics, irrigation, and mineral oil 1, 2.

Proper Administration Technique

Before applying drops, clean the ear canal by suctioning debris and discharge under microscopic guidance to enhance drug delivery to the middle ear space. 1, 2 Use tissue spears to absorb secretions and facilitate drop entry 1, 2.

Administration steps:

• Warm the bottle in hand for 1-2 minutes to avoid dizziness from cold solution 3
• Patient lies with affected ear upward 3
• Instill prescribed number of drops 3
• Pump the tragus 4 times by pushing inward to facilitate middle ear penetration 3
• Maintain position for 5 minutes 3

For significant canal edema, place a compressed cellulose wick moistened with aqueous solution before medication application 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 present
• Extension of infection outside ear canal
• Diabetes or immunocompromised state
• Topical therapy fails after 48-72 hours despite adequate drug delivery

First-line systemic antibiotic: Amoxicillin targeting S. pneumoniae, H. influenzae, and M. catarrhalis 4, 2

Second-line: Amoxicillin-clavulanate for β-lactamase-producing organisms 4, 2

Duration: 5-7 days for acute otitis media 2

Note that oral antibiotics alone are inferior to topical therapy for localized infection, delivering drug concentrations 100-1000 times lower at the infection site 1, 2.

Pain Management

Provide adequate analgesia as perforation pain can be intense due to periosteum proximity: 4, 2

• Mild to moderate pain: Acetaminophen or NSAIDs 4, 2
• Moderate to severe pain: Combination products with oxycodone or hydrocodone 4, 2

Ear Protection Measures

Keep the ear dry to prevent infection: 1, 2

• Use ear plugs or cotton balls coated with petroleum jelly when showering 1, 2
• Avoid swimming until healed 1, 2
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 1, 2
• Avoid cotton-tipped applicators as they may cause further trauma or leave behind fibers 1, 2

Reassessment and Follow-Up

If no clinical improvement within 48-72 hours, reassess the patient to: 5, 1

• Confirm diagnosis and exclude other causes 1
• Assess adherence to therapy and successful physical placement of drops 5
• Perform further aural debridement or suctioning 1, 2
• Culture persistent drainage to detect fungi, MRSA, or resistant bacteria 1, 2

Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 1. Most traumatic perforations heal spontaneously, with 74% closing without intervention and 62% healing within 3 months 6.

Special Populations

For diabetic or immunocompromised patients: Have a lower threshold for systemic antibiotics and consider atraumatic cleaning with aural suctioning under microscopic guidance 4, 2.

For fungal otomycosis with perforation: Use topical antifungal therapy, with oral antifungals reserved for refractory cases 4, 2.

Key Clinical Pitfall

If a patient tastes ear drops, this indicates perforation—they must inform their physician immediately to switch to a non-ototoxic preparation. 1, 2