What is the treatment for a patient with a ruptured eardrum?

Treatment of Ruptured Eardrum

Most ruptured eardrums heal spontaneously without intervention—the primary treatment is keeping the ear dry and avoiding further trauma, with topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone) reserved only for cases with active infection. 1, 2

Initial Assessment

Confirm the diagnosis through careful otoscopic examination, documenting the size and location of the perforation 1. Look specifically for:

• Blood or purulent discharge in the ear canal (suction carefully rather than irrigate) 2
• Vertigo, nausea, or vomiting (suggests ossicular chain disruption) 2
• Conductive hearing loss >30 dB on audiometry (indicates possible ossicular damage) 2
• Profound sensorineural hearing loss (signifies inner ear nerve damage requiring urgent ENT referral) 2

Check for modifying factors like diabetes or immunocompromised status, which increase infection risk and may require systemic antibiotics 1.

Conservative Management for Uncomplicated Perforations

Ear Protection (Critical)

• Keep the ear completely dry to prevent infection 1, 3
• Use earplugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming entirely until the perforation heals 1, 3
• Never irrigate the ear canal—this can cause middle ear infection, vertigo, or ototoxicity 1, 3

What NOT to Do

• Never use cotton-tipped applicators in the ear canal (risk of further trauma or leaving fibers behind) 1
• Avoid all cerumenolytic drops (wax-softening agents) when perforation is present or suspected 1, 3
• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations)—these cause severe permanent sensorineural hearing loss through perforations 1
• Avoid alcohol-containing drops—painful and ototoxic in the middle ear 1

Treatment of Infected Perforations

When to Use Topical Antibiotics

Prescribe topical therapy only when there is active infection with otorrhea (drainage from the ear) 1. Do not use antibiotics prophylactically for clean, dry perforations 2.

First-Line Topical Therapy

Fluoroquinolone drops are the ONLY safe topical antibiotics for perforated eardrums 1, 4:

• Ofloxacin 0.3% otic solution: 10 drops twice daily for 14 days in patients ≥12 years 4
• Ciprofloxacin-dexamethasone combination: Superior efficacy due to corticosteroid component 1

These achieve drug concentrations 100-1000 times higher than oral antibiotics at the infection site 1.

Administration Technique

1. Clean the ear canal first by suctioning debris and discharge (never irrigate) 1
2. Warm the bottle in your hand for 1-2 minutes to prevent dizziness 4
3. Patient lies with affected ear upward 4
4. Instill drops, then pump the tragus 4 times to facilitate middle ear penetration 4
5. Maintain position for 5 minutes 4
6. Limit treatment to ≤10 days to prevent otomycosis from prolonged quinolone use 1

When to Add Systemic Antibiotics

Add oral antibiotics ONLY when 1:

• Cellulitis of the pinna or adjacent skin is present
• Topical therapy fails after 48-72 hours despite adequate drug delivery
• Diabetes or immunocompromised state exists
• Signs of severe infection (fever, systemic symptoms)

Note: Oral antibiotics alone are inferior to topical therapy for localized infection 1.

If Treatment Fails

• Reassess at 48-72 hours to confirm diagnosis and exclude other causes 1
• Repeat aural debridement/suctioning to improve drug delivery 1
• Culture persistent drainage for fungi or MRSA (though quinolones usually succeed despite reported resistance due to high local concentrations) 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Surgical Referral Indications

Refer to ENT when 5, 2:

• Perforation persists >6 months (warrants tympanoplasty) 5
• Immediate complete facial nerve paralysis (requires urgent CT temporal bone and possible surgery) 5
• Persistent vertigo or worsening sensorineural hearing loss (suspect perilymphatic fistula) 5
• Conductive hearing loss >30 dB (suspect ossicular chain damage) 2
• Perforation from blast trauma, thermal, or caustic injury (less likely to heal spontaneously) 5

Prognosis

Most traumatic perforations from penetrating or blunt injuries heal spontaneously with good outcomes 5, 2. Small perforations typically resolve without intervention when kept dry 2. However, biannual follow-up for minimum 2 years is recommended due to cholesteatoma formation risk 5.