What is the diagnosis and management for a patient with a 1-day history of right ear pain and muffled hearing, who has a history of ear infections, is hemodynamically stable, afebrile, with a swollen External Auditory Canal (EAC) and erythema, and a perforated Tympanic Membrane (TM) after ear lavage due to cerumen impaction?

Diagnosis and Management of Acute Otitis Externa with Iatrogenic Tympanic Membrane Perforation

This patient has acute otitis externa (AOE) complicated by an iatrogenic tympanic membrane perforation from ear lavage, requiring immediate initiation of non-ototoxic topical fluoroquinolone therapy and strict water precautions.

Diagnosis

The clinical picture confirms acute otitis externa with tympanic membrane perforation:

• AOE diagnostic criteria are met: The patient has rapid onset (<6 weeks) with characteristic symptoms (ear pain, muffled hearing) and signs (EAC erythema, edema, tragal tenderness would be expected) 1
• The perforation is iatrogenic: Ear lavage in the setting of pre-existing infection likely caused the perforation, as irrigation should be avoided when TM perforation is present or suspected 1, 2
• This is NOT acute otitis media: Despite TM involvement, pneumatic otoscopy would show good TM mobility with AOE (if the membrane were intact), distinguishing it from AOM which shows absent/limited mobility 1

Immediate Management Algorithm

Step 1: Stop All Water Exposure

• Keep the ear completely dry to prevent worsening infection 3, 2
• Use ear plugs or cotton balls coated with petroleum jelly when showering 3, 2
• Absolutely no swimming until perforation heals 3, 2

Step 2: Prescribe Non-Ototoxic Topical Antibiotics

First-line therapy: Ciprofloxacin-dexamethasone or ofloxacin otic drops 3, 2, 4

• These are the ONLY safe topical antibiotics for perforated TMs—fluoroquinolones lack ototoxicity even with direct middle ear exposure 3, 2
• Ciprofloxacin-dexamethasone combination is preferred over antibiotics alone for superior efficacy 3, 2
• Topical therapy delivers drug concentrations 100-1000 times higher than oral antibiotics can achieve 3, 2

Dosing for ofloxacin (if patient ≥13 years old): 10 drops (0.5 mL) into affected ear twice daily for 14 days for perforated TM 5

Administration technique 3, 2, 5:

1. Warm bottle in hand for 1-2 minutes
2. Patient lies with affected ear upward
3. Instill drops
4. Pump tragus 4 times to facilitate middle ear penetration
5. Maintain position for 5 minutes

Step 3: Aural Toilet Before Drop Administration

• Suction debris and discharge from the EAC before applying drops to enhance drug delivery 3, 2
• Use gentle suction or tissue spears to absorb secretions 2
• This step is critical—topical therapy fails without adequate canal cleaning 2

Step 4: Provide Adequate Analgesia

• Prescribe appropriate oral analgesics for the significant pain associated with AOE 1, 6

Critical Medications to AVOID

NEVER use these preparations with a perforated TM 3, 2:

• Aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—cause severe permanent sensorineural hearing loss 3, 2
• Alcohol-containing preparations—painful and potentially ototoxic in middle ear space 3, 2
• Any cerumenolytics or irrigation—contraindicated with non-intact TM 2

When to Add Systemic Antibiotics

Do NOT prescribe oral antibiotics as initial therapy 2. Add systemic antibiotics ONLY if 3, 2:

• Cellulitis of pinna or adjacent skin develops
• Signs of severe infection appear
• Topical therapy fails after 48-72 hours despite adequate drug delivery
• Patient has diabetes or is immunocompromised (lower threshold for systemic therapy)

Follow-Up and Reassessment

• Reassess at 48-72 hours if no clinical improvement 1, 3, 2
• At reassessment, confirm diagnosis and exclude complications (malignant otitis externa, mastoiditis) 1
• Only 4-8% of patients require oral antibiotic rescue therapy 2
• Most uncomplicated AOE resolves within 6-7 days 6

Special Considerations and Pitfalls

Common Pitfall: The Lavage Should Not Have Been Performed

Ear irrigation is contraindicated when TM perforation is suspected 1. Before irrigation, a detailed history should identify risk factors for perforation (history of ear infections, prior ear surgery, tympanostomy tubes) 1. If any portion of the TM is visible and mobile with pneumatic otoscopy, irrigation may proceed cautiously 1.

Watch for Complications

• Malignant (necrotizing) otitis externa: If patient develops mastoid tenderness, headache, vertigo, meningismus, or neurological deficits, urgent imaging and specialist referral are required 1
• Persistent perforation: If TM does not heal within 1 month, otolaryngology referral is indicated 7
• Otomycosis: Prolonged quinolone use (>10 days) increases fungal infection risk—limit treatment duration 2

Patient Warning Sign

If the patient tastes the ear drops, this confirms TM perforation—they should report this immediately 2

No Imaging Required

Imaging has no role in uncomplicated AOE with TM perforation 1. CT or MRI is reserved only for suspected complications like skull base osteomyelitis, intracranial extension, or when diagnosis is uncertain 1.