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

Treatment of Ruptured Tympanic Membrane

For a ruptured eardrum, keep the ear dry, use topical fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) if infection is present, and avoid ototoxic preparations—most perforations heal spontaneously with conservative management. 1

Initial Assessment

• Confirm the diagnosis through otoscopic examination, documenting the size and location of the perforation 1
• Check for modifying factors including diabetes, immunocompromised status, or signs of infection extending beyond the ear canal 1
• Distinguish between simple traumatic perforation and infection-related perforation, as this determines whether antibiotics are needed 1

Conservative Management for Uncomplicated Perforations

Most traumatic tympanic membrane perforations (95%) heal spontaneously without intervention 2

Ear Protection Measures

• Keep the ear completely dry to prevent infection—use ear plugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has completely healed 1
• Never irrigate the ear canal when perforation is present or suspected, as this causes middle ear infection, vertigo, or ototoxicity 1

What to Avoid

• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations)—these cause severe permanent sensorineural hearing loss after exposure through perforations 1
• Avoid alcohol-containing drops, as alcohol in the middle ear space is painful and ototoxic 1
• Do not use cotton-tipped applicators in the ear canal—they cause further trauma or leave behind fibers 1
• Avoid cerumenolytics or mineral oil when the tympanic membrane is not intact 1

Topical Antibiotic Therapy (When Infection Present)

Use topical fluoroquinolone antibiotics as first-line treatment when infection is present—they are safe with middle ear exposure and deliver 100-1000 times higher drug concentrations than oral antibiotics 1

Specific Antibiotic Selection

• Ofloxacin otic solution: 10 drops (0.5 mL) twice daily for 14 days in patients ≥12 years with perforated tympanic membranes 3
• Ciprofloxacin-dexamethasone combination drops: Superior efficacy due to the addition of corticosteroid 1
• Both fluoroquinolones lack ototoxicity even with direct middle ear exposure 1

Application Technique

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

When Topical Therapy Fails

• Reassess within 48-72 hours if no improvement 1
• Consider further aural debridement or suctioning to facilitate drug delivery 1
• Culture persistent drainage to detect fungi or MRSA, though quinolones typically succeed despite reported resistance due to high local concentrations 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Systemic Antibiotics (Limited Indications)

Reserve systemic antibiotics for specific situations only—oral antibiotics alone are inferior to topical therapy for localized infection 1

Add or Switch to Systemic Antibiotics When:

• Cellulitis of the pinna or adjacent skin is present 1
• Signs of infection extending outside the ear canal 1
• Patient has diabetes or is immunocompromised 1
• Topical therapy fails after 48-72 hours despite adequate drug delivery 1

Special Clinical Scenarios

Blast Injuries

• Blast-related perforations carry risk of secondary cholesteatomas and require surgical exploration with middle ear inspection and relining of the perforation 2
• This is an exception to the watchful waiting approach 2

Perforations with Significant Canal Edema

• Place a wick made of compressed cellulose, moistened with aqueous solution before medication application, to facilitate drug delivery 1

Follow-Up and Monitoring

• Reassess if symptoms persist beyond 2 weeks or if the patient fails to respond to initial therapy within 48-72 hours 1, 4
• Ensure otorhinolaryngologic follow-up to confirm healing 2

Critical Warning Signs

• If a patient tastes ear drops, this indicates a perforated eardrum—they should inform their doctor immediately 1
• Obtain detailed history including previous ear surgery, as the tympanic membrane may be thinned or atrophic and vulnerable 1