What is the treatment for a patient with a ruptured tympanic membrane (ear drum)?

Treatment for Ruptured Ear Drum

Immediate Management: Keep the Ear Dry and Avoid Harmful Interventions

The primary treatment for most ruptured tympanic membranes is conservative management with strict ear protection, avoiding water exposure and ototoxic substances, as the majority heal spontaneously within 6-8 weeks. 1, 2, 3

Critical Actions to Avoid

• Never irrigate the ear canal when perforation is present or suspected—this can cause middle ear infection, vertigo, or permanent ototoxicity 1, 4
• Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations 1
• Do not use alcohol-containing drops as alcohol in the middle ear space is both painful and potentially ototoxic 1
• Avoid cotton-tipped applicators in the ear canal as they may cause further trauma or leave behind fibers 1

Ear Protection Protocol

• Instruct patients to keep the ear completely dry to prevent infection 1, 4
• Use ear plugs or cotton balls coated with petroleum jelly when showering 1
• Avoid swimming until the perforation has completely healed 1

When to Use Topical Antibiotics

Use topical fluoroquinolone antibiotics ONLY if there are signs of infection (otorrhea, inflammation, pain). For asymptomatic perforations, antibiotics are not indicated. 1

First-Line Topical Therapy (If Infection Present)

Fluoroquinolone eardrops are the ONLY safe topical antibiotics for ruptured tympanic membranes:

• Ofloxacin 0.3% solution OR Ciprofloxacin-dexamethasone combination drops are first-line choices 1, 5
• These achieve drug concentrations 100-1000 times higher than systemic antibiotics at the infection site 1
• Ciprofloxacin-dexamethasone combination is superior to antibiotics alone for clinical efficacy 1

Proper Administration Technique

1. Clean the ear canal first by suctioning debris and discharge to enhance drug delivery 1
2. Warm the bottle in hand for 1-2 minutes to avoid dizziness 1, 5
3. Have patient lie with affected ear upward 1, 5
4. Instill appropriate dose (see below) 5
5. Pump the tragus 4 times by pushing inward to facilitate middle ear penetration 1, 5
6. Maintain position for 5 minutes 1, 5

Dosing for Perforated Tympanic Membrane with Infection

For chronic suppurative otitis media with perforation (patients ≥12 years):

• Ofloxacin: 10 drops (0.5 mL) into affected ear twice daily for 14 days 5

For acute otitis media with tympanostomy tubes (ages 1-12 years):

• Ofloxacin: 5 drops (0.25 mL) into affected ear twice daily for 10 days 5

Treatment Duration and Monitoring

• Limit topical therapy to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1
• Reassess within 48-72 hours if no response to confirm diagnosis and exclude other causes 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

When to Add Systemic Antibiotics

Add or switch to systemic antibiotics only in these specific situations: 1

• Cellulitis of the pinna or adjacent skin is present 1
• Signs of severe infection or extension beyond the ear canal 1
• Patient has diabetes or is immunocompromised 1
• Topical therapy fails after 48-72 hours despite adequate drug delivery 1
• Concurrent bacterial infection exists 1

High-dose amoxicillin (500 mg every 8 hours or 875 mg every 12 hours for adults) for 5 days may be considered in these scenarios. 1

Follow-Up and Surgical Considerations

• Most traumatic perforations heal spontaneously within 6-8 weeks 2, 3, 6
• Perforations lasting 6 months after injury warrant surgical referral 7
• Biannual follow-up for minimum of 2 years is recommended as any traumatic perforation carries risk of cholesteatoma formation 7
• ENT referral is needed for: persistent perforation beyond 1 month, associated vertigo, significant hearing loss (>30 dB conductive loss suggesting ossicular chain disruption), facial paralysis, or continuous pain 2, 3, 7

Special Populations

Patients with diabetes or immunocompromised states require special caution and lower threshold for systemic antibiotics due to higher risk of complications including malignant otitis externa 1, 4

Children: All pediatric cases in one series healed spontaneously without surgery 6

Warning Sign for Patients

If a patient tastes ear drops, this likely indicates a perforated eardrum and they should inform their doctor immediately 1