What is the treatment for a patient with a sloughed (eardrum that has fallen off) eardrum and loss of hearing?

Treatment of Sloughed Eardrum with Hearing Loss

Immediate referral to an otolaryngologist is mandatory for a sloughed (completely perforated) tympanic membrane with hearing loss, as this requires specialist evaluation to determine if surgical repair (tympanoplasty) is needed and to prevent chronic complications including permanent conductive hearing loss and recurrent infections. 1

Immediate Management Priorities

Distinguish Type of Hearing Loss

• Perform tuning fork testing (Weber and Rinne) immediately to differentiate conductive hearing loss (from the perforation itself) from sensorineural hearing loss, which may indicate inner ear damage requiring urgent treatment 1
• A sloughed tympanic membrane typically causes conductive hearing loss, but if sensorineural hearing loss is present, this represents a medical emergency requiring corticosteroids within 2 weeks 1, 2, 3
• Complete audiometric evaluation with air and bone conduction thresholds is essential to quantify the hearing loss and guide treatment decisions 3

Protect the Ear and Prevent Infection

• Keep the ear completely dry—no water exposure, no irrigation, no ear drops unless specifically prescribed as non-ototoxic 1
• If infection is present (otorrhea, pain, erythema), prescribe only non-ototoxic topical antibiotics such as fluoroquinolone otic preparations, as aminoglycosides and other ototoxic agents can cause permanent sensorineural hearing loss when applied to a perforated tympanic membrane 1
• Atraumatic cleaning with aural suctioning under microscopic guidance may be needed if debris is present 1

Specialist Evaluation Requirements

Otolaryngology Assessment

• Microscopic examination of the perforation to assess size, location, and whether the edges are healthy tissue capable of healing 1
• Evaluation for middle ear pathology including cholesteatoma, ossicular discontinuity, or chronic otitis media that may have caused the perforation 1
• Assessment for tympanosclerosis or other structural abnormalities that affect prognosis 1

Audiologic Testing

• Formal audiometry cannot wait—it must be performed to establish baseline hearing and determine if conductive, sensorineural, or mixed hearing loss is present 1, 3
• Speech audiometry and word recognition scores help determine functional impact and candidacy for amplification 3
• If asymmetric sensorineural hearing loss is found (≥15 dB difference at 2+ frequencies between ears), MRI of the internal auditory canals is mandatory to exclude retrocochlear pathology such as vestibular schwannoma 1, 3

Treatment Algorithm Based on Findings

If Pure Conductive Hearing Loss from Perforation

• Watchful waiting for 3-6 months is appropriate for small perforations that may heal spontaneously 1
• Tympanoplasty (surgical repair) is indicated if the perforation does not heal, if hearing loss is significant (>25-30 dB), or if recurrent infections occur 1, 4
• Hearing aids may provide temporary benefit while awaiting surgery or if surgery is contraindicated 3

If Sensorineural Component Present

• Immediate corticosteroids (prednisone 60-80 mg daily for 10 days) if sensorineural hearing loss developed acutely within the past 2 weeks 1, 5
• MRI with gadolinium dedicated to internal auditory canals to exclude stroke, tumor, or other retrocochlear pathology 3, 5
• Chronic sensorineural hearing loss from longstanding perforation and recurrent infections requires audiologic rehabilitation with hearing aids or cochlear implantation depending on severity 3, 4

If Chronic Suppurative Otitis Media

• Surgical intervention with tympanoplasty is preferred over prolonged medical management, as chronic infection increases risk of progressive sensorineural hearing loss from toxin absorption into the cochlea 4
• Adenoidectomy may be considered if nasal obstruction or chronic adenoiditis is present 1

Critical Pitfalls to Avoid

• Never irrigate or instill ototoxic drops (aminoglycosides, alcohol-based preparations) into an ear with known or suspected perforation—this causes irreversible sensorineural hearing loss 1
• Do not dismiss this as benign—a sloughed tympanic membrane with hearing loss can progress to chronic otitis media with cholesteatoma, ossicular erosion, and permanent hearing loss if untreated 1, 4
• Do not delay audiometry—waiting to "see if it gets better" risks missing sudden sensorineural hearing loss, where treatment delay beyond 2 weeks significantly worsens prognosis 1, 2
• Do not assume the hearing loss is purely conductive—always perform tuning fork tests and audiometry to identify any sensorineural component requiring urgent treatment 1

Patient Counseling and Follow-Up

• Educate about water precautions: no swimming, use earplugs or cotton with petroleum jelly during showering until the perforation heals or is surgically repaired 1
• Counsel on infection risk: any new ear drainage, pain, or worsening hearing requires immediate medical attention 1
• Discuss realistic expectations: spontaneous healing occurs in some cases, but surgical repair may be necessary for persistent perforation or significant hearing loss 1
• Address impact on communication, safety, and quality of life, especially if bilateral involvement or significant hearing loss is present 1, 3
• Schedule follow-up within 2-4 weeks to reassess perforation healing and hearing status, with repeat audiometry at 3-6 months 2, 3