What is the treatment for a patient with a ruptured tympanic membrane?

Treatment of Ruptured Tympanic Membrane

First-Line Treatment: Topical Fluoroquinolone Antibiotics

For ruptured tympanic membranes with infection, use topical fluoroquinolone antibiotics (ciprofloxacin-dexamethasone or ofloxacin) as first-line therapy, avoiding all aminoglycoside-containing drops which cause permanent hearing loss. 1, 2

Why Topical Therapy is Superior

• Topical antibiotics deliver drug concentrations 100-1000 times higher at the infection site compared to oral antibiotics 1, 2
• Combination antibiotic-corticosteroid drops (ciprofloxacin-dexamethasone) are superior to antibiotics alone for clinical efficacy 1, 2
• Fluoroquinolones are the only safe topical antibiotics because they lack ototoxicity even with direct middle ear exposure 1, 2

Specific Medication Dosing

For Chronic Suppurative Otitis Media with Perforation (Age ≥12 years)

• Ofloxacin otic: 10 drops (0.5 mL) into affected ear twice daily for 14 days 3

For Acute Otitis Media with Tympanostomy Tubes (Ages 1-12 years)

• Ofloxacin otic: 5 drops (0.25 mL) into affected ear twice daily for 10 days 3

Treatment Duration

• Limit topical therapy to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use 1, 2

Critical Administration Technique

Proper instillation is essential for drug delivery to the middle ear:

1. Warm the bottle in hand for 1-2 minutes to avoid dizziness 1, 3
2. Clean the ear canal first by suctioning debris and discharge under microscopic guidance 1, 2
3. Have patient lie with affected ear upward 1, 3
4. Instill drops, then pump the tragus 4 times by pushing inward 1, 3
5. Maintain position for 5 minutes to facilitate middle ear penetration 1, 3

Absolutely Contraindicated Medications

Never use the following in perforated tympanic membranes:

• Aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) - cause severe permanent sensorineural hearing loss after exposure through perforations 1, 2
• Alcohol-containing drops - painful and potentially ototoxic in middle ear space 1, 2
• Cerumenolytics or mineral oil 1, 2
• Ear irrigation - can cause middle ear infection, vertigo, or ototoxicity 1, 2

When to Add Systemic Antibiotics

Reserve systemic antibiotics only for specific indications: 1, 2

• Cellulitis of pinna or adjacent skin
• Extension of infection outside ear canal
• Diabetes or immunocompromised state
• Topical therapy failure after 48-72 hours despite adequate drug delivery
• Signs of severe infection

Systemic Antibiotic Selection

• First choice: Amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for 5-7 days (targets S. pneumoniae, H. influenzae, M. catarrhalis) 1, 2
• Second choice: Amoxicillin-clavulanate for β-lactamase-producing organisms 2

Ear Protection Measures

Keep the ear dry to prevent infection: 1, 2

• Use ear plugs or cotton balls coated with petroleum jelly when showering
• Avoid swimming until perforation has healed
• Never use cotton-tipped applicators in the ear canal - they cause further trauma or leave behind fibers 1, 2

Pain Management

Provide adequate analgesia as perforation pain can be intense: 2

• Mild to moderate pain: acetaminophen or NSAIDs
• Moderate to severe pain: combination products with oxycodone or hydrocodone

Reassessment and Follow-Up

If no response within 48-72 hours: 1, 2

• Reassess to confirm diagnosis and exclude other causes
• Perform further aural debridement or suctioning
• Culture persistent drainage to detect fungi or MRSA
• Only 4-8% of patients require oral antibiotic rescue therapy 1

Spontaneous Healing Expectations

Most traumatic perforations heal spontaneously: 4, 5, 6

• 94% of traumatic perforations heal without intervention 7
• All children in one study demonstrated complete spontaneous recovery 5
• Healing is delayed by large perforations (≥50% of tympanic membrane), ear discharge, and penetrating injuries through the ear canal 7

Red Flags Requiring ENT Referral

Refer to otolaryngology when: 6

• Vertigo, nausea, or vomiting (suggests ossicular chain disruption)
• Conductive hearing loss >30 dB (suggests ossicular chain disruption)
• Profound sensorineural loss (suggests inner ear nerve damage)
• Perforation from chronic otitis media or cholesteatoma
• Perforation from acute otitis media that does not heal within one month
• Continuous pain or facial paralysis 4

Common Pitfalls to Avoid

• If patient tastes ear drops, this indicates perforation - switch immediately to non-ototoxic fluoroquinolone preparation 1, 2
• Even when tympanic membrane cannot be visualized due to canal edema or debris, assume perforation may be present and avoid aminoglycosides 1
• Never irrigate the ear canal when perforation is present or suspected 1, 2