What is the recommended treatment for an adult patient with a ruptured eardrum (tympanic membrane perforation)?

Treatment of Ruptured Eardrum in Adults

Most ruptured eardrums heal spontaneously with conservative management—keep the ear dry, avoid ototoxic drops, and use topical fluoroquinolone antibiotics only if infection develops. 1, 2

Initial Assessment

When evaluating a ruptured eardrum, confirm the diagnosis through careful otoscopic examination, noting the size and location of the perforation. 1 Look specifically for:

• Signs of infection: otorrhea, canal edema, erythema 1
• Perforation characteristics: size (small/medium/large), location (quadrant), edges 1, 3
• Associated injuries: ossicular damage, facial nerve involvement, perilymphatic fistula (especially with blast or severe trauma) 4
• Host factors: diabetes, immunocompromised state 1, 2

Avoid pneumatic otoscopy and irrigation when perforation is suspected, as these can worsen injury or introduce infection. 2

Conservative Management for Uncomplicated Perforations

For asymptomatic or minimally symptomatic perforations without infection, watchful waiting is the standard approach, as 95% heal spontaneously. 5

Ear Protection Measures

• Keep the ear dry to prevent infection—use earplugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has healed 1
• Do not use cotton-tipped applicators in the ear canal, as they may cause further trauma or leave behind fibers 1, 2

Pain Management

Pain from tympanic membrane perforation can be intense due to proximity of the periosteum. 2

• Mild to moderate pain: acetaminophen or NSAIDs 6, 2
• Moderate to severe pain: combination products with oxycodone or hydrocodone 6, 2
• Administer analgesics at fixed intervals rather than as-needed for better pain control 6

Expected Healing Timeline

• Small to medium perforations (Griffin grade I, 97% of traumatic cases): typically heal within 2-4 weeks 5, 7
• Large perforations: may take 6-8 weeks 3, 7
• Perforations persisting beyond 6 months warrant surgical referral 4

Management When Infection is Present

If otorrhea, canal inflammation, or signs of infection develop, topical fluoroquinolone antibiotics are the treatment of choice. 1, 2

Topical Antibiotic Selection

Use only non-ototoxic fluoroquinolone preparations:

• Ofloxacin 0.3% otic solution: 10 drops twice daily for 14 days in adults with perforated tympanic membranes 8, 9
• Ciprofloxacin-dexamethasone combination: provides superior efficacy with added anti-inflammatory benefit 1, 2

Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics at the infection site. 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

Additional contraindications:

• Alcohol-containing drops: painful and potentially ototoxic in the middle ear 1
• Cerumenolytics or irrigation: can cause further damage 2
• Benzocaine otic solutions: not FDA-approved for middle ear use 6

Proper Drop Administration

1. Clean the ear canal first by suctioning debris and discharge under microscopic guidance to enhance drug delivery 1, 2
2. Warm the bottle in hand for 1-2 minutes to avoid dizziness from cold solution 8
3. Have patient lie with affected ear upward 8
4. Instill drops, then pump the tragus 4 times by pushing inward to facilitate middle ear penetration 8
5. Maintain position for 5 minutes 8
6. Limit treatment to 10 days maximum to prevent otomycosis from prolonged quinolone use 1

When to Add Systemic Antibiotics

Reserve oral antibiotics for specific indications only, as topical therapy is superior for localized infection. 1, 2

Add systemic antibiotics when:

• Extension of infection beyond the ear canal (cellulitis of pinna or adjacent skin) 1, 2
• Host factors present: diabetes, immunocompromised state 1, 2
• Failure to improve within 48-72 hours despite adequate topical therapy 1, 2
• Concurrent acute otitis media with systemic symptoms 2

For systemic therapy, use agents targeting S. pneumoniae, H. influenzae, and M. catarrhalis:

• First-line: amoxicillin or amoxicillin-clavulanate 2
• Alternative: fluoroquinolones (ciprofloxacin or levofloxacin) for Pseudomonas coverage if external canal involvement 6

Reassessment and Follow-Up

Reassess at 48-72 hours if no improvement occurs. 6, 1

At reassessment, evaluate:

• Adherence to therapy and proper drop administration technique 6
• Need for further aural debridement or suctioning 1
• Alternative diagnoses (fungal infection, cholesteatoma, chronic suppurative otitis media) 6, 4
• Culture persistent drainage to detect fungi or resistant bacteria 1

All traumatic perforations require biannual follow-up for minimum 2 years due to risk of cholesteatoma formation. 4

Surgical Considerations

Refer for surgical repair if:

• Perforation persists beyond 6 months 4
• Blast injury mechanism (higher risk of secondary cholesteatoma) 5
• Suspected ossicular chain damage with conductive hearing loss 4
• Immediate complete facial nerve paralysis 4
• Perilymphatic fistula with persistent vestibular symptoms 4

Novel surgical adjuvants showing promise include basic fibroblast growth factor (b-FGF) with gelatin sponge (98.1% closure rate vs. 10% with saline) and bioengineered scaffolds. 2

Common Pitfalls to Avoid

• Never irrigate the ear when perforation is present or suspected—this causes middle ear infection, vertigo, or ototoxicity 1, 2
• Do not prescribe neomycin-containing drops even for "just a few days"—single courses carry lower but real risk of permanent hearing loss 1
• Assume tympanostomy tubes are patent for 6-12 months after placement and treat as non-intact tympanic membrane 1
• If you cannot visualize the tympanic membrane due to canal edema or debris, assume perforation may be present and avoid ototoxic preparations 1
• If patient tastes ear drops, this indicates perforation—stop ototoxic preparations immediately 1