What is the appropriate treatment for a patient with a ruptured tympanic membrane (eardrum)?

Treatment of Ruptured Tympanic Membrane

Immediate Management

Most traumatic tympanic membrane perforations heal spontaneously with conservative management, requiring only ear protection and avoidance of water exposure, with 95% achieving complete closure without intervention. 1

Essential Protective Measures

• Keep the ear completely dry to prevent secondary infection—use ear plugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until the perforation has healed 2
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind cotton fibers 2
• Never irrigate the ear canal when tympanic membrane perforation is present or suspected, as this can lead to middle ear infection, vertigo, or ototoxicity 2

When to Use Topical Antibiotics

Indications for Treatment

• Prescribe topical antibiotics only if signs of infection develop (purulent drainage, pain, erythema), not prophylactically 2
• Topical therapy is preferred over systemic antibiotics because drug concentrations at the site can be 100-1000 times higher than serum levels achieved with oral antibiotics 2

Safe Antibiotic Selection

• Use only fluoroquinolone-based topical antibiotics (ofloxacin or ciprofloxacin-dexamethasone) as they lack ototoxicity even with direct middle ear exposure 2, 3
• Completely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations 2
• Avoid alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic 2

Proper Administration Technique

• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery 2
• Warm the bottle in your hand for 1-2 minutes to avoid dizziness from cold solution instillation 3
• Have the patient lie with the affected ear up, instill drops, then pump the tragus 4 times by pushing inward to facilitate middle ear penetration 2, 3
• Maintain this position for 5 minutes after instillation 3
• Limit topical therapy to a single course of no more than 10 days to avoid complications like otomycosis from prolonged quinolone use 2

When to Use Systemic Antibiotics

Add or switch to systemic antibiotics only in specific high-risk situations:

• Cellulitis of the pinna or adjacent skin is present 2
• Signs of severe infection or extension outside the ear canal 2
• Patient has diabetes or is immunocompromised 2
• Topical therapy fails after 48-72 hours despite adequate drug delivery 2

Follow-Up and Surgical Considerations

• Most traumatic perforations (95%) heal spontaneously within 6-8 weeks with conservative management 1, 4
• Ofloxacin drops may shorten closure time for medium and large perforations, though spontaneous healing remains the norm 5
• Perforations lasting 6 months after injury warrant surgical referral for tympanoplasty 6
• Blast injuries are an exception—these require early surgical exploration due to risk of secondary cholesteatoma formation 1
• Biannual follow-up for a minimum of 2 years is recommended as any traumatic perforation carries risk of cholesteatoma formation 6

Critical Pitfalls to Avoid

• If a patient tastes ear drops, this indicates a perforated eardrum—they should inform their doctor immediately and the drops should be discontinued if they contain ototoxic agents 2
• Never assume the tympanic membrane is intact if you cannot visualize it due to canal edema or debris—treat as if a perforation may be present 2
• Patients with tympanostomy tubes should be treated as having non-intact tympanic membranes for at least 6-12 months after placement 2