What is the recommended treatment for a patient with a perforated eardrum?

Treatment of Perforated Eardrum

For a perforated eardrum, use topical fluoroquinolone ear drops (ofloxacin 0.3% or ciprofloxacin-dexamethasone) as first-line treatment if infection is present, while keeping the ear dry and avoiding ototoxic preparations—never use aminoglycoside-containing drops like neomycin or gentamicin. 1

Immediate Management Priorities

Confirm the Diagnosis

• Perform careful otoscopic examination to note the size and location of the perforation 1
• Assess for modifying factors including diabetes, immunocompromised state, or history of ear surgery 1
• Critical warning sign: If the patient tastes ear drops after instillation, this confirms tympanic membrane perforation 1

Essential Ear Protection Measures

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

Treatment Algorithm Based on Clinical Presentation

For Asymptomatic or Clean Perforations (No Infection)

• Conservative management is appropriate for most traumatic perforations, as 70-93% heal spontaneously within 1-2 months 2, 3
• Keep the ear dry and follow up in 1 month 2
• Refer to otolaryngology if no healing occurs after 1 month, or if there is associated vertigo or significant hearing loss (>30 dB conductive loss suggesting ossicular chain disruption) 2

For Infected Perforations (Otorrhea Present)

First-Line: Topical Fluoroquinolone Antibiotics

• Use ofloxacin 0.3% or ciprofloxacin-dexamethasone drops exclusively—these are the only safe topical antibiotics for perforated eardrums due to lack of ototoxicity even with direct middle ear exposure 1
• Topical therapy delivers drug concentrations 100-1000 times higher than systemic antibiotics and achieves superior clinical cure rates (77-96% vs 30-67% for oral antibiotics) 1, 4
• Clean the ear canal first by suctioning debris and discharge before administering drops to enhance drug delivery 1

Dosing and Administration 5:

• For otitis externa with perforation in patients ≥13 years: 10 drops (0.5 mL) once daily for 7 days
• For chronic suppurative otitis media with perforation in patients ≥12 years: 10 drops twice daily for 14 days
• Warm the bottle in hand for 1-2 minutes, have patient lie with affected ear upward, instill drops, pump the tragus 4 times, and maintain position for 5 minutes 5

Why Fluoroquinolones Are Superior:

• Ciprofloxacin-dexamethasone combination is first-line due to superior clinical efficacy and cost-effectiveness compared to antibiotics alone 1
• Fluoroquinolones provide excellent coverage against Pseudomonas aeruginosa and Staphylococcus aureus, which cause 98% of ear infections 1

Absolutely Contraindicated Medications

Never Use These Preparations 1:

• Aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—these cause severe permanent sensorineural hearing loss after prolonged or repetitive administration through perforations
• Alcohol-containing drops—painful and potentially ototoxic in the middle ear space
• Mineral oil or oil-based preparations—contraindicated as they can access middle ear structures
• Cerumenolytics—avoid when tympanic membrane is not intact

When to Add or Switch to Systemic Antibiotics

Indications for Oral Antibiotics 1, 6:

• Extension of infection beyond the ear canal (cellulitis of pinna or adjacent skin)
• Diabetes mellitus or immunocompromised state
• Signs of severe infection
• Topical therapy failure after 48-72 hours despite adequate drug delivery
• Concurrent bacterial infection

Recommended Systemic Antibiotic:

• Oral fluoroquinolones (e.g., ciprofloxacin) for coverage against Pseudomonas aeruginosa and Staphylococcus aureus 6
• High-dose amoxicillin (500 mg every 8 hours or 875 mg every 12 hours for 5 days) may be considered as an alternative 1

Special Considerations and High-Risk Populations

Diabetic or Immunocompromised Patients

• Monitor carefully for necrotizing otitis externa, which can initially present with symptoms similar to uncomplicated otitis externa 6
• Consider adding systemic antibiotics even for seemingly uncomplicated cases 6
• Avoid aggressive irrigation—use atraumatic suctioning under microscopic guidance instead 6
• Higher susceptibility to otomycosis (fungal infection) 6

Suspected Fungal Infection (Otomycosis)

• Suspect if white fuzzy exudate with pruritus and discharge is present 6
• Treat with thorough but gentle debridement of fungal debris and topical antifungal preparations 3-4 times daily for 7-10 days 6
• Avoid antibacterial drops that may promote fungal overgrowth 1, 6

Expected Clinical Course and Follow-Up

• Pain typically improves within 48-72 hours of starting treatment 1
• Clinical resolution occurs within 7-10 days in 65-90% of patients 1
• Reassess within 48-72 hours if no improvement to confirm diagnosis and exclude other causes 1
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 1

Reasons for Treatment Failure 1, 6:

• Inadequate drug delivery due to canal obstruction
• Poor adherence to therapy
• Allergic contact dermatitis from topical agents (especially neomycin, which causes reactions in 5-15% of patients)
• Fungal co-infection
• Incorrect diagnosis

Critical Pitfalls to Avoid

• Never use cotton-tipped applicators in the ear canal—they may cause further trauma or leave behind fibers 1
• Never irrigate when perforation is present or suspected 1
• Never prescribe oral antibiotics as initial therapy for uncomplicated cases—topical therapy is superior 1, 6
• Never use ototoxic preparations when tympanic membrane integrity is compromised 1, 6
• Failing to clean the ear canal before administering drops reduces effectiveness 1
• Missing fungal infections, especially in diabetics or those who fail antibacterial therapy 6

Pain Management

• Assess pain severity and prescribe appropriate analgesics based on intensity 1, 6
• Acetaminophen or NSAIDs for mild-to-moderate pain 6
• Short-term opioids may be needed for severe pain during the initial 48-72 hours 6
• Pain typically improves within 48-72 hours of starting topical therapy 1, 6