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

Treatment of Perforated Eardrum

For a perforated eardrum, keep the ear dry and use topical fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) if infection is present, while strictly avoiding aminoglycoside-containing drops and ear irrigation. 1

Immediate Management Based on Infection Status

If No Signs of Infection Present

• Keep the ear completely dry by using earplugs or cotton balls coated with petroleum jelly when showering, and avoid swimming until healed 1
• Avoid ear irrigation entirely, as this can cause middle ear infection, vertigo, or ototoxicity 2, 1
• Do not use cerumen-removing drops or softening agents unless specifically cleared by an otolaryngologist 2
• Most traumatic perforations heal spontaneously without intervention 3, 4
• Confirm diagnosis with otoscopic examination, noting perforation size and location 1

If Infection or Drainage Present

First-line treatment is topical fluoroquinolone antibiotics, which are the only safe options for perforated eardrums:

• Ciprofloxacin-dexamethasone combination drops are preferred as first-line therapy due to superior efficacy and cost-effectiveness 1
• Ofloxacin drops are an alternative safe fluoroquinolone option 2, 1
• These achieve drug concentrations 100-1000 times higher than oral antibiotics at the infection site 1

Critical administration technique:

• Clean the ear canal first by suctioning debris and discharge before applying drops 1
• Warm the bottle in hand for 1-2 minutes 1
• Have patient lie with affected ear upward 1
• Pump the tragus 4 times after instillation 1
• Maintain position for 5 minutes 1
• Limit treatment to maximum 10 days to prevent otomycosis from prolonged quinolone use 1

Medications to Absolutely Avoid

Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations), as they cause severe permanent sensorineural hearing loss after exposure through perforations 1

Avoid alcohol-containing drops, which are both painful and potentially ototoxic in the middle ear space 1

Do not use cotton-tipped applicators, as they may cause further trauma or leave behind fibers 1

When to Add Systemic Antibiotics

Systemic antibiotics are not initial therapy for uncomplicated perforations 1. Add oral antibiotics only when:

• Cellulitis of the pinna or adjacent skin is present 1
• Signs of severe infection exist 1
• Patient has diabetes or is immunocompromised 1
• Topical therapy fails after 48-72 hours despite adequate drug delivery 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Reassessment and Follow-Up

• If no response within 48-72 hours, reassess to confirm diagnosis and exclude other causes 1, 4
• 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

Special Populations Requiring Extra Caution

• Patients with diabetes have higher risk of malignant otitis externa and require special attention 2, 1
• Immunocompromised patients should be considered for earlier systemic antibiotic therapy 1
• Patients with tympanostomy tubes should be treated as having non-intact tympanic membranes—assume tubes are patent for at least 6-12 months after placement 1

Red Flags Requiring ENT Referral

Refer to otolaryngology when:

• Continuous pain, vertigo, or facial paralysis present 3
• Perforation persists beyond one month 4
• Significant hearing loss (>30 dB conductive loss suggests ossicular chain disruption) 4
• Profound sensorineural loss (may signify inner ear nerve damage) 4
• Chronic perforation from chronic otitis media or cholesteatoma, which usually requires surgical repair 3

Common Pitfalls to Avoid

• If patient tastes ear drops, this indicates perforation—stop immediately and inform physician 1
• Never irrigate the ear when perforation is present or suspected 2, 1
• Avoid using any preparation not specifically cleared for perforated membranes, as substances can access middle ear structures and cause permanent hearing damage 1
• Even when you cannot visualize the tympanic membrane due to canal edema or debris, assume a perforation may be present and use only non-ototoxic preparations 1