What is the recommended treatment for a patient with a perforated tympanic membrane?

Treatment for Perforated Tympanic Membrane

For perforated tympanic membranes with infection, use topical fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) as first-line therapy, while asymptomatic perforations require only ear protection and observation for spontaneous healing. 1

Initial Assessment

Confirm the diagnosis through careful otoscopic examination, noting the size and location of the perforation. 1 Key assessment points include:

• Assess for modifying factors that influence management: diabetes, immunocompromised state, prior radiotherapy, or tympanostomy tubes. 2, 3
• Evaluate for pain severity to guide analgesic selection—pain can be intense due to proximity of the periosteum. 4, 3
• Check for signs suggesting ossicular chain disruption: vertigo, nausea, vomiting, or conductive hearing loss >30 dB. 5
• Avoid irrigation and pneumatic otoscopy when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity. 1, 4, 5

Pain Management

Provide adequate analgesia based on pain severity: acetaminophen or NSAIDs for mild-to-moderate pain; combination products with oxycodone or hydrocodone for moderate-to-severe pain. 4, 3 Administer analgesics on a scheduled basis rather than as-needed, as pain is easier to prevent than treat. 3

Ear Protection (All Perforations)

Keep the ear dry to prevent infection: use earplugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until healed. 1, 4 This applies to all perforations regardless of whether infection is present.

Topical Antibiotic Therapy (When Infection Present)

Use only non-ototoxic fluoroquinolone eardrops when treating infected perforations:

• First-line options: ofloxacin or ciprofloxacin-dexamethasone combination drops. 1, 3 The combination antibiotic-corticosteroid preparations are superior to antibiotics alone for efficacy. 1
• Rationale: Fluoroquinolones achieve drug concentrations 100-1000 times higher than systemic antibiotics at the infection site and lack ototoxicity even with direct middle ear exposure. 1
• Treatment duration: Limit to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use. 1

Critical Contraindications

Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations), as they cause severe permanent sensorineural hearing loss after prolonged or repetitive administration through perforations. 1, 4 Also avoid alcohol-containing drops, which are painful and potentially ototoxic in the middle ear space. 1

Proper Administration Technique

Clean the ear canal first by suctioning debris and discharge to enhance drug delivery to the middle ear space. 1, 3 Then:

• Warm the bottle in hand for 1-2 minutes. 1
• Have the patient lie with the affected ear upward. 1
• Instill drops, pump the tragus 4 times, and maintain position for 5 minutes. 1
• For significant canal edema, place a wick (preferably compressed cellulose) to facilitate drug delivery. 1

Systemic Antibiotics (Limited Indications)

Do not prescribe systemic antimicrobials as initial therapy for uncomplicated perforations. 2 Add or switch to systemic antibiotics only when: 1, 3

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection exist
• Patient has diabetes or is immunocompromised
• Topical therapy fails after 48-72 hours despite adequate drug delivery
• Concurrent acute otitis media with systemic symptoms

When systemic antibiotics are indicated, target S. pneumoniae, H. influenzae, and M. catarrhalis with amoxicillin (500 mg every 8 hours or 875 mg every 12 hours for adults) for 5 days, or use β-lactamase-stable agents given current resistance patterns. 4

Follow-Up and Reassessment

If no response within 48-72 hours, reassess to confirm the diagnosis and exclude other causes. 2, 1, 3 Consider:

• Further aural debridement or suctioning to facilitate drug delivery. 1
• Culture persistent drainage to detect pathogens like fungi or MRSA. 1
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms. 1

Spontaneous Healing Expectations

Most small perforations resolve spontaneously, with 67.5% healing without intervention. 5, 6 Healing timeline:

• <2 weeks: 22% of cases 6
• <4 weeks: 33% of cases 6
• <3 months: 19% of cases 6
• <6 months: 11% of cases 6
• ≥6 months: 15% of cases (but all showed signs of closure by 6 months) 6

All children with traumatic perforations heal spontaneously. 7

Surgical Referral Indications

Consider otolaryngologic referral for:

• Perforations in contact with the malleus (associated with lower spontaneous closure rates). 6
• Traumatic perforations with vertigo or significant hearing loss (>30 dB conductive loss). 5
• Perforations from chronic otitis media. 5
• Perforations that fail to show signs of healing within 6 months. 6
• Perforations from acute otitis media that do not heal within one month. 5

Surgical options include cartilage reconstruction (superior to temporalis fascia) or tissue-engineered myringoplasty with basic fibroblast growth factor (98.1% closure rate versus 10% with saline). 4

Common Pitfalls to Avoid

• Never irrigate the ear canal when perforation is present or suspected. 1, 4
• Avoid cotton-tipped applicators in the ear canal, as they may cause further trauma or leave behind fibers. 1
• Do not use cerumenolytics or mineral oil when the tympanic membrane is not intact. 1
• Assume tympanostomy tubes are patent for at least 6-12 months after placement and treat as non-intact membranes. 1
• If the patient tastes ear drops, this indicates perforation—inform them to notify their doctor immediately. 1