What is the treatment for a patient with a tympanic membrane rupture?

Treatment of Tympanic Membrane Rupture

For tympanic membrane perforation with infection, use topical fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) as first-line therapy, keep the ear dry, provide adequate analgesia, and avoid all ototoxic preparations including aminoglycosides. 1, 2

Initial Assessment and Pain Control

• Assess pain severity immediately and provide appropriate analgesics on a scheduled basis rather than as-needed, since pain prevention is more effective than treatment 2
• Use acetaminophen or NSAIDs for mild-to-moderate pain; reserve opioid combinations for severe pain 2
• Pain can be severe because the highly sensitive periosteum of the underlying bone lies in close proximity to the ear canal 2
• Confirm the diagnosis through careful otoscopic examination, documenting perforation size and location 1
• Assess for modifying factors including diabetes, immunocompromised state, or prior radiotherapy that may influence management 1, 2

Ear Protection (Critical for All Perforations)

• Instruct patients to keep the ear completely dry to prevent middle ear infection 1
• Use earplugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming entirely until the perforation has healed 1
• Never irrigate the ear canal when perforation is present or suspected, as this causes middle ear infection, vertigo, or ototoxicity 1

Topical Antibiotic Therapy (When Infection Present)

Safe First-Line Options

• Use fluoroquinolone eardrops exclusively: ofloxacin or ciprofloxacin-dexamethasone 1, 2
• These are the only topical antibiotics safe for perforated tympanic membranes due to complete lack of ototoxicity even with direct middle ear exposure 1
• Ciprofloxacin-dexamethasone combination is superior to antibiotics alone for clinical efficacy and cost-effectiveness 1
• Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics can achieve at the infection site 1

Specific Dosing (FDA-Approved)

For chronic suppurative otitis media with perforation (age ≥12 years): 3

• Ofloxacin 10 drops (0.5 mL) into affected ear twice daily for 14 days 3

For acute otitis media with tympanostomy tubes (age 1-12 years): 3

• Ofloxacin 5 drops (0.25 mL) into affected ear twice daily for 10 days 3

Critical Administration Technique

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

Absolutely Contraindicated Preparations

• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations 1, 2
• Avoid alcohol-containing drops—alcohol in the middle ear is painful and ototoxic 1
• Do not use cerumenolytics or mineral oil when the tympanic membrane is not intact 1
• Avoid cotton-tipped applicators as they cause further trauma or leave behind fibers 1

When to Add Systemic Antibiotics

Reserve systemic antibiotics for specific indications only: 1, 2

• Cellulitis of the pinna or adjacent skin 1
• Signs of severe infection or extension outside the ear canal 1
• Concurrent acute otitis media 2
• Diabetes or immunocompromised state 1
• Failure of topical therapy after 48-72 hours despite adequate drug delivery 1, 2

Important: Systemic antibiotics should be prescribed in addition to, not instead of, topical therapy when indicated 2

Follow-Up and Reassessment

• If no response within 48-72 hours, reassess to confirm diagnosis and exclude other causes 1, 2
• 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

Special Situations Requiring ENT Referral

• Traumatic perforations associated with vertigo or significant hearing loss (>30 dB conductive loss suggests ossicular chain disruption) 4
• Profound sensorineural hearing loss suggesting inner ear nerve damage 4
• Perforations from chronic otitis media or cholesteatoma that will not heal without surgery 5
• Continuous pain, facial paralysis, or other alarming signs 5
• Perforations from acute otitis media that do not heal within one month 4

Expected Outcomes

• Most small traumatic perforations resolve spontaneously without intervention 4, 5, 6
• All children in one series (n=20) demonstrated complete spontaneous recovery 6
• Mean healing time for those completing follow-up is approximately 6 weeks 6