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

Treatment of Ruptured Tympanic Membrane

For a ruptured tympanic membrane with infection, use topical fluoroquinolone drops (ciprofloxacin-dexamethasone or ofloxacin) as first-line treatment after cleaning the ear canal, while keeping the ear dry and avoiding all aminoglycoside-containing drops that cause permanent hearing loss. 1, 2

Initial Assessment

Confirm the diagnosis through otoscopic examination, noting the size and location of the perforation 1. Key modifying factors to assess include:

• Diabetes or immunocompromised state 1, 2
• Prior ear surgery or tympanostomy tubes 1
• Signs of infection extension (cellulitis of pinna, facial paralysis, vertigo) 3, 4
• Hearing loss severity (>30 dB conductive loss suggests ossicular chain disruption) 4

Treatment Algorithm

For Uncomplicated Traumatic Perforations (No Infection)

Most traumatic perforations heal spontaneously within 4-6 weeks and require only observation with ear protection. 3, 5

• Keep the ear dry: Use ear plugs or cotton balls coated with petroleum jelly when showering; avoid swimming until healed 1, 2
• No antibiotics needed for clean traumatic perforations without signs of infection 1, 2
• Provide adequate analgesia: Use acetaminophen or NSAIDs for mild-moderate pain; oxycodone or hydrocodone combinations for moderate-severe pain 2
• Reassess at 48-72 hours if symptoms worsen 1, 2

For Perforations with Infection

Topical fluoroquinolone therapy is superior to systemic antibiotics, delivering drug concentrations 100-1000 times higher at the infection site. 1, 2

Step 1: Clean the Ear Canal First

• Suction debris and discharge under microscopic guidance before applying any drops 1, 2
• Use tissue spears to absorb secretions 1, 2
• For significant canal edema, place a compressed cellulose wick moistened with aqueous solution 1, 2

Step 2: Apply Topical Fluoroquinolone Drops

First-line medication: Ciprofloxacin-dexamethasone combination drops (superior efficacy and cost-effectiveness) 1, 2

Alternative: Ofloxacin drops 1, 2

Administration technique:

• Warm bottle in hand for 1-2 minutes 1
• Patient lies with affected ear upward 1
• Instill drops, pump tragus 4 times, maintain position for 5 minutes 1

Duration: Limit to single course of no more than 10 days to prevent otomycosis 1, 2

Step 3: Reassess at 48-72 Hours

If no improvement 1, 2:

• Perform further aural debridement or suctioning 1, 2
• Culture persistent drainage (though quinolones typically succeed despite reported resistance) 1
• Only 4-8% of patients require oral antibiotic rescue therapy 1

When to Add Systemic Antibiotics

Reserve systemic antibiotics only for specific indications 1, 2:

• Cellulitis of pinna or adjacent skin 1, 2
• Extension of infection outside ear canal 1, 2
• Diabetes or immunocompromised state 1, 2
• Topical therapy failure after 48-72 hours despite adequate drug delivery 1, 2
• Signs of severe infection 1, 2

First choice: Amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for 5-7 days 1, 2

Second choice: Amoxicillin-clavulanate for β-lactamase-producing organisms 2

Critical Medications to AVOID

Never use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—they cause severe permanent sensorineural hearing loss after exposure through perforations. 1, 2

Also avoid 1, 2:

• Alcohol-containing drops (painful and ototoxic in middle ear) 1
• Cerumenolytics 1, 2
• Ear canal irrigation (can cause middle ear infection, vertigo, or ototoxicity) 1, 2
• Mineral oil 1
• Cotton-tipped applicators (cause further trauma or leave fibers) 1, 2

Warning Sign for Patients

If the patient tastes ear drops, this indicates perforation—they must inform you immediately to switch to non-ototoxic preparation. 1, 2

When to Refer to ENT

Refer for otolaryngologic evaluation when 3, 4, 6:

• Vertigo, nausea, or vomiting (suggests ossicular chain disruption or perilymphatic fistula) 4, 6
• Conductive hearing loss >30 dB 4
• Profound sensorineural hearing loss (suggests inner ear nerve damage) 4
• Facial paralysis 3, 6
• Continuous pain 3
• Perforation persists beyond 1-6 months 3, 4, 6
• Blast injuries or thermal/caustic injuries (less likely to heal spontaneously) 6
• Suspected cholesteatoma 6

Special Populations

Children: All pediatric traumatic perforations in one study healed spontaneously without intervention 5

Diabetic or immunocompromised patients: Have lower threshold for systemic antibiotics and consider atraumatic cleaning with aural suctioning under microscopic guidance 2

Fungal otomycosis with perforation: Use topical antifungal therapy; oral antifungals for refractory cases 2

Follow-Up

Biannual follow-up for minimum of two years is recommended, as any traumatic tympanic membrane perforation carries risk of cholesteatoma formation 6