What is the best course of treatment for a patient with a history of punctured tympanic membrane, now presenting with redness and difficulty hearing?

Treatment of Tympanic Membrane Perforation with Redness and Hearing Loss

For a patient with a history of tympanic membrane perforation now presenting with redness and difficulty hearing, initiate topical fluoroquinolone antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) twice daily for up to 10 days as first-line therapy. 1, 2

Diagnostic Confirmation

• Confirm the perforation through careful otoscopic examination, noting the size and location of the defect 2
• The presence of redness with a known perforation and hearing loss suggests acute infection (acute otitis media with perforation) rather than simple chronic perforation 1, 3
• Avoid pneumatic otoscopy and irrigation when perforation is present or suspected, as these can cause middle ear infection, vertigo, or ototoxicity 2, 3
• Document the degree of hearing loss, as this helps differentiate simple conductive loss from potential ossicular chain disruption (which would show >30 dB conductive loss) 3

First-Line Treatment Protocol

Topical fluoroquinolone therapy is superior to oral antibiotics for perforated acute otitis media and should be used as primary treatment. 1, 2

• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery to the middle ear space 2
• Prescribe topical fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) twice daily for up to 10 days 1, 2
• Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics can achieve at the infection site 2
• Have the patient lie with the affected ear up for 3-5 minutes after instillation and "pump" the tragus several times to facilitate middle ear penetration 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. 2, 4

• Avoid alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic 2
• Do not use ototoxic preparations even when you cannot visualize the tympanic membrane due to canal edema or debris—assume a perforation may be present 2
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 2

When to Add Systemic Antibiotics

Add or switch to systemic antibiotics only in specific circumstances: 2

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection or extension beyond the ear canal exist
• Patient has diabetes or is immunocompromised 5, 2
• Topical therapy fails after 48-72 hours despite adequate drug delivery 2

For systemic therapy when indicated, use high-dose amoxicillin (500 mg every 8 hours or 875 mg every 12 hours for adults) for 5 days 1

Reassessment and Follow-Up

• If the patient fails to respond to initial therapy within 48-72 hours, reassess to confirm the diagnosis and exclude other causes 2
• Consider further aural debridement or suctioning to facilitate drug delivery if treatment is not progressing 2
• Culture persistent drainage to detect pathogens like fungi or MRSA, though quinolone antibiotics typically succeed even with reported resistance due to high local concentrations 2
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 2

Ear Protection During Treatment

• Instruct the patient to keep the ear dry to prevent further infection 2, 3
• Use ear plugs or cotton balls coated with petroleum jelly when showering 2
• Avoid swimming until the perforation has healed 2

Key Clinical Pitfall

If a patient tastes ear drops, this is a sign of perforation and confirms middle ear access—ensure you are using only non-ototoxic fluoroquinolone preparations in this scenario. 2