What is the assessment and treatment plan for a patient with a ruptured eardrum (tympanic membrane perforation)?

Assessment and Plan for Ruptured Eardrum (Tympanic Membrane Perforation)

Assessment

Confirm the diagnosis through careful otoscopic examination, documenting the size, location, and characteristics of the perforation. 1

Key Diagnostic Elements

• Visualize the perforation directly - note whether it's small (most traumatic perforations are Griffin grade I in 97% of cases) or larger (subtotal/total), and document which quadrants are involved (most commonly upper anterior and lower posterior) 1, 2

• Determine the etiology - distinguish between traumatic causes (impact to ear, barotrauma, foreign body), infectious causes (acute or chronic otitis media), or iatrogenic causes (ear irrigation, instrumentation) 1, 3, 4

• Assess for modifying factors that influence management:

  • Diabetes or immunocompromised state (higher risk for complications) 1, 3
  • History of prior ear surgery (may have atrophic or vulnerable tympanic membrane) 1, 3
  • Presence of infection signs (otorrhea, canal edema, erythema) 1
  • Associated symptoms: hearing loss, otalgia, vertigo, facial paralysis 4

• Rule out complications - examine for cellulitis extending beyond the ear canal, signs of mastoiditis, or ossicular discontinuity 1

• Consider tympanometry if swelling or discomfort don't preclude its use (though this will show abnormal findings with perforation) 1

Plan

Immediate Management - Ear Protection

Instruct the patient to keep the ear completely dry to prevent infection - use earplugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until healed. 1, 5

• Never irrigate the ear when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 1, 5

• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 1

Topical Antibiotic Therapy (If Infection Present)

Use only fluoroquinolone-based topical antibiotics (ofloxacin or ciprofloxacin-dexamethasone) as they are non-ototoxic even with direct middle ear exposure. 1, 6

• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery 1

• Dosing for ofloxacin with perforation (chronic suppurative otitis media): 10 drops (0.5 mL) into affected ear twice daily for 14 days in patients ≥12 years 6

• Administration technique: Warm bottle in hand 1-2 minutes, have patient lie with affected ear up, instill drops, pump tragus 4 times inward, maintain position for 5 minutes 1, 6

• Limit treatment to ≤10 days to prevent otomycosis from prolonged quinolone use 1

• Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations) - these cause severe permanent sensorineural hearing loss after exposure through perforations 1, 5

• Avoid alcohol-containing drops as alcohol in the middle ear is painful and potentially ototoxic 1

Systemic Antibiotics (Selective Use Only)

Reserve oral antibiotics for specific indications only, as topical therapy delivers 100-1000 times higher drug concentrations at the infection site. 1

Add systemic antibiotics when:

• Cellulitis of pinna or adjacent skin is present 1
• Signs of severe infection or extension beyond ear canal 1
• Patient has diabetes or is immunocompromised 1, 3
• Topical therapy fails after 48-72 hours despite adequate drug delivery 1

Watchful Waiting vs. Surgical Intervention

For traumatic perforations without infection, adopt watchful waiting with otolaryngologic follow-up, as 95% close spontaneously. 2

• Small perforations (Griffin grade I) should be left to heal spontaneously 7, 2

• Reassess at 48-72 hours if infection was present to confirm response to therapy 1

• Refer to ENT if:

  • Perforation persists beyond 3 months 7
  • Subtotal or total rupture present 7
  • Blast injury (risk of secondary cholesteatoma - requires surgical exploration) 2
  • Alarming signs: continuous pain, vertigo, facial paralysis 4
  • Suspected ossicular discontinuity or cholesteatoma 4, 7

Critical Pitfalls to Avoid

• Never use cerumenolytics or irrigation when tympanic membrane is not intact 1, 5

• If patient tastes ear drops, this indicates perforation - stop immediately and reassess 1

• Assume perforation may be present if you cannot visualize the tympanic membrane due to canal edema or debris, and avoid ototoxic preparations 1

• Treat patients with tympanostomy tubes as having non-intact membranes - assume tubes are patent for at least 6-12 months after placement 1