What is the management plan for a patient with a removed eardrum (tympanic membrane removal)?

Management of Tympanic Membrane Removal

Critical First Principle: Avoid All Ototoxic Preparations

When the tympanic membrane is removed or perforated, fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) are the ONLY safe topical antibiotics, as they lack ototoxicity even with direct middle ear exposure. 1

• Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations 1
• Avoid all alcohol-containing preparations as alcohol in the middle ear space is both painful and potentially ototoxic 1
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 2, 1

Immediate Protective Measures

Keep the ear dry to prevent infection - this is the cornerstone of preventing complications 1:

• Use ear plugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has healed 1
• Do not use cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 1

Topical Antibiotic Therapy (If Infection Present)

Ciprofloxacin-dexamethasone combination drops are first-line therapy due to superior 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
• Clean the ear canal FIRST by suctioning debris and discharge before applying any drops to enhance drug delivery 1
• Limit treatment to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1

Proper Administration Technique

• Warm the bottle in hand for 1-2 minutes 1
• Have patient lie with affected ear upward 1
• Instill drops, pump the tragus 4 times, and maintain position for 5 minutes 1

When to Add Systemic Antibiotics

Systemic antibiotics should be added or substituted when 1:

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection are present
• Topical therapy fails after 48-72 hours despite adequate drug delivery
• Patient has diabetes or is immunocompromised

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

Special Considerations for Diabetic Patients

• Exercise extreme caution with any ear manipulation in diabetic patients due to higher risk of malignant otitis externa 2
• Consider reacidifying the ear canal with vinegar or acetic acid drops after treatment 2
• Lower threshold for systemic antibiotics in this population 1

Surgical Referral Indications

Refer to otolaryngology when 2:

• Repeated attempts at management are unsuccessful
• Complications are encountered
• Patient is no longer tolerating treatment efforts
• Specialized equipment (microscope, otoendoscope, aural microsuction) is needed

Common Pitfalls to Avoid

• Never assume the tympanic membrane is intact if you cannot visualize it due to canal edema or debris - treat as if perforation is present 1
• Avoid cerumenolytics or irrigation when the tympanic membrane is not intact 1
• If patient tastes ear drops, this indicates perforation - they should inform their doctor immediately 1
• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 1