What is the best course of action for a patient with a history of possible tympanic membrane (eardrum) perforation and chronic pain in the right ear, who has been previously evaluated for vertigo and dizziness, and now presents with a feeling of heaviness in the ear, but denies vertigo, tinnitus, and hearing problems?

Management of Chronic Tympanic Membrane Perforation with Ear Pain and Fullness

This patient should receive an ENT referral for comprehensive evaluation, as she has a known tympanic membrane perforation with chronic symptoms that warrant specialist assessment for potential surgical repair. 1

Immediate Assessment and Precautions

Critical Safety Measures

• The ear must be kept dry at all times to prevent infection through the perforation—use ear plugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until evaluated by ENT 1
• Never irrigate the ear canal when tympanic membrane perforation is present or suspected, as this can lead to middle ear infection, vertigo, or ototoxicity 1
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind cotton fibers 1

Physical Examination Priorities

• Perform careful otoscopic examination to confirm the perforation and document its size and location 1
• Assess for signs of active infection (otorrhea, canal edema, debris) 2
• Evaluate for any neurologic findings, particularly given her history of vertigo and dizziness 2

Indications for ENT Referral (This Patient Meets Multiple Criteria)

Absolute Indications Present in This Case

• Chronic perforation with persistent symptoms (chronic pain and ear fullness) 3, 4
• History of vertigo/dizziness previously evaluated—requires comprehensive vestibular assessment 3
• Perforation of uncertain duration ("history of hole")—perforations lasting six months after injury warrant surgical evaluation 5

Additional Red Flags to Assess (Rule These Out)

• Continuous or severe pain (may indicate cholesteatoma or chronic infection) 4
• Conductive hearing loss >30 dB (suggests ossicular chain disruption) 3
• Facial nerve symptoms or paralysis 4, 5
• Persistent or worsening vestibular symptoms 5

Management While Awaiting ENT Evaluation

If No Active Infection Present (As in This Case)

• No antibiotics are indicated for asymptomatic or minimally symptomatic perforations without signs of infection 1
• Continue ear protection measures (keep dry) 1
• Avoid any ototoxic preparations 1

If Active Infection Develops Before ENT Visit

• Use only fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone)—these are the ONLY safe topical antibiotics for perforated tympanic membranes 1
• Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations) as they cause severe permanent sensorineural hearing loss through perforations 1
• Clean the ear canal by suctioning debris before applying drops to enhance drug delivery 1
• Limit topical therapy to no more than 10 days 1

Expected ENT Evaluation and Treatment Options

Diagnostic Testing the Specialist May Order

• Audiogram to assess hearing level and type of hearing loss 2
• Tympanometry (if tolerated) 1
• Video/electronystagmography for vestibular function given her vertigo history 2
• High-resolution CT of temporal bone if ossicular damage or other complications suspected 5

Surgical Considerations

• Most chronic perforations require surgical repair (tympanoplasty) as they will not heal spontaneously 4
• Perforations persisting beyond 6 months after injury warrant surgery 5
• Endoscopic type I tympanoplasty has 86% closure rate with mean surgery time of 48.6 minutes 6
• Any traumatic perforation carries risk of cholesteatoma formation, requiring biannual follow-up for minimum of 2 years 5

Common Pitfalls to Avoid

• Do not assume the perforation will heal spontaneously—while traumatic perforations from blunt/penetrating injuries often heal spontaneously (70-93% in some series), chronic perforations of uncertain etiology typically require surgical intervention 4, 7
• Do not prescribe ear drops "just in case"—only treat active infection, and only with fluoroquinolones 1
• Do not delay referral—chronic symptoms with known perforation warrant specialist evaluation regardless of current symptom severity 3, 4