What ear drops are recommended for a patient with a perforated eardrum (tympanic membrane perforation)?

Fluoroquinolone Ear Drops Are the Only Safe Option for Perforated Eardrums

For any patient with a perforated tympanic membrane (or when perforation cannot be ruled out), use only topical fluoroquinolone ear drops—specifically ofloxacin 0.3% or ciprofloxacin 0.2%—and absolutely avoid aminoglycoside-containing preparations (neomycin, gentamicin, polymyxin B combinations) which cause permanent sensorineural hearing loss. 1

First-Line Treatment: Ofloxacin or Ciprofloxacin

Ofloxacin 0.3% is the preferred fluoroquinolone because it does not delay tympanic membrane healing, unlike ciprofloxacin-dexamethasone combinations which significantly prolong healing time. 1, 2, 3

Dosing for Perforated Tympanic Membrane:

• Adults and children ≥13 years: 10 drops (0.5 mL) into affected ear twice daily for 14 days 4
• Children 1-12 years with tympanostomy tubes: 5 drops (0.25 mL) twice daily for 10 days 4
• Otitis externa (intact membrane): 10 drops once daily for 7 days in adults; 5 drops once daily for 7 days in children 6 months-13 years 4

Why Fluoroquinolones Are Superior:

• Achieve drug concentrations 100-1000 times higher than systemic antibiotics at the infection site 1
• Cover the two pathogens responsible for 98% of ear infections: Pseudomonas aeruginosa and Staphylococcus aureus 1
• Non-ototoxic even with direct middle ear exposure through perforations 1, 5
• Clinical cure rates of 75-91% for chronic suppurative otitis media with perforated membranes 5

Critical Administration Technique

Proper technique is essential—only 40% of patients self-administer drops correctly during the first 3 days. 6

Step-by-Step Instructions:

1. Clean the ear canal first by suctioning debris and discharge—medication cannot reach infected tissues through debris 1
2. Warm the bottle in your hand for 1-2 minutes to prevent dizziness 4
3. Have someone else administer drops if possible (significantly improves adherence) 6
4. Lie with affected ear upward 4
5. Instill prescribed number of drops to fill the ear canal 1
6. Pump the tragus 4 times by pushing inward to facilitate middle ear penetration 4
7. Maintain position for 5 minutes 4
8. Wipe off excess after sitting up 6

Absolutely Contraindicated Preparations

Never use these with perforated or potentially perforated eardrums:

• Aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—cause severe permanent sensorineural hearing loss after prolonged or repetitive administration through perforations 1
• Alcohol-containing drops—painful and potentially ototoxic in the middle ear space 1
• Cerumenolytics or mineral oil—contraindicated with non-intact tympanic membranes 1
• Irrigation—can cause middle ear infection, vertigo, or ototoxicity when perforation is present 1

When to Add Systemic Antibiotics

Topical therapy alone is sufficient for most cases. Only add oral antibiotics when: 1

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

If systemic antibiotics are needed: Use fluoroquinolones (ciprofloxacin) for Pseudomonas and Staphylococcus coverage. 6

Special Populations Requiring Modified Management

Diabetic or Immunocompromised Patients:

• Use atraumatic suctioning under microscopic guidance instead of irrigation—irrigation can trigger necrotizing otitis externa 6
• Monitor carefully for necrotizing otitis externa, which can present initially like uncomplicated infection 6
• Consider adding systemic antibiotics even for seemingly uncomplicated cases 6
• Higher susceptibility to fungal infections (otomycosis) 6

Patients with Tympanostomy Tubes:

• Treat as having non-intact tympanic membranes—assume tubes are patent for at least 6-12 months after placement 1
• Use only fluoroquinolone preparations 1

Expected Clinical Course and Reassessment

• Pain typically improves within 48-72 hours of starting treatment 1

• If no improvement at 48-72 hours, reassess for: 1

  • Inadequate drug delivery due to canal obstruction
  • Poor adherence to therapy
  • Fungal co-infection (especially in diabetics)
  • Allergic contact dermatitis from topical agents
  • Incorrect diagnosis

• Only 4-8% of patients require oral antibiotic rescue therapy for persistent symptoms 1

Critical Warning Signs

If the patient tastes the ear drops, this indicates a tympanic membrane perforation—inform the doctor immediately. 1

Common Pitfalls to Avoid

• Using aminoglycoside-containing drops when membrane integrity is uncertain 1
• Failing to clean the ear canal before administering drops 1
• Irrigating the ear when perforation is present or suspected 1
• Using cotton-tipped applicators which may cause further trauma 1
• Prescribing oral antibiotics for uncomplicated cases (occurs inappropriately in 20-40% of patients) 6

Ciprofloxacin-Dexamethasone: Use with Caution

While ciprofloxacin-dexamethasone combination drops have superior clinical efficacy, they significantly delay tympanic membrane healing compared to ofloxacin alone. 2, 3 In rat studies, ciprofloxacin-dexamethasone delayed healing up to 35 days, with some perforations not healing by day 40, whereas all ofloxacin-treated perforations healed by day 10. 2 For perforated membranes, ofloxacin monotherapy is preferred to avoid delayed healing. 1, 7

Human studies confirm that ofloxacin drops actually shorten closure time and improve closure rates of traumatic tympanic membrane perforations, particularly for large perforations. 7