How should a ruptured eardrum (tympanic membrane perforation) be managed in a child?

Management of Ruptured Eardrum in Children

Most ruptured eardrums in children heal spontaneously within 2-3 months with conservative management, requiring only ear protection and observation, but if infection is present, topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin-dexamethasone) are the only safe choice. 1, 2

Initial Assessment and Diagnosis

• Confirm the perforation through careful otoscopic examination, documenting the size, location, and whether it contacts the malleus (which predicts lower spontaneous healing rates). 1, 3
• Avoid pneumatic otoscopy and irrigation when perforation is present or suspected, as these can cause middle ear infection, vertigo, or ototoxicity. 1, 4
• Assess for modifying factors including diabetes, immunocompromised state, or signs of infection extending beyond the ear canal. 1, 5

Conservative Management for Uncomplicated Perforations

Most small perforations (67-70%) resolve spontaneously, with healing occurring within 2 weeks in some cases, though 4 cases may take up to 6 months. 3, 6

Ear Protection Measures

• Keep the ear dry to prevent secondary infection by using ear plugs or cotton balls coated with petroleum jelly when showering. 1
• Avoid swimming until the perforation has healed completely. 1
• Do not use cotton-tipped applicators in the ear canal, as they may cause further trauma or leave behind fibers. 1

Observation Timeline

• Observe for spontaneous closure for up to 6 months if signs of healing are present, as all perforations showing healing signs by 6 months eventually closed in one study. 3
• Consider surgical referral after 3 months if no improvement occurs, or earlier if perforation contacts the malleus (associated with lower spontaneous closure rates). 1, 3

Management When Infection is Present

Topical Antibiotic Therapy (First-Line)

Topical fluoroquinolone antibiotics are the ONLY safe choice for perforated eardrums, achieving drug concentrations 100-1000 times higher than oral antibiotics at the infection site. 1, 5

• Use ciprofloxacin-dexamethasone or ofloxacin drops as first-line therapy due to superior clinical efficacy and complete lack of ototoxicity even with direct middle ear exposure. 1, 5
• NEVER use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations), as they cause severe permanent sensorineural hearing loss after exposure through perforations. 1, 7

Critical Administration Technique

• Clean the ear canal first by suctioning debris and discharge to enhance drug delivery to the middle ear space. 1
• Warm the bottle in hand for 1-2 minutes, have the child lie with affected ear upward, instill drops, pump the tragus 4 times, and maintain position for 5 minutes. 1
• Limit treatment to a single course of no more than 10 days to prevent otomycosis from prolonged quinolone use. 1

When to Add Oral Antibiotics

Oral antibiotics are inferior to topical therapy for localized infection but should be added when: 1, 2

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection exist
• The child has diabetes or is immunocompromised
• Topical therapy fails after 48-72 hours despite adequate drug delivery

If oral antibiotics are needed, use high-dose amoxicillin 80-90 mg/kg/day as first-line therapy, switching to amoxicillin-clavulanate if no improvement within 48-72 hours. 2

Pain Management

• Address pain aggressively with acetaminophen or ibuprofen regardless of treatment approach, as pain significantly impacts quality of life. 2
• Avoid alcohol-containing drops, as alcohol in the middle ear space is both painful and potentially ototoxic. 1

Follow-Up and Monitoring

• Reassess within 48-72 hours if infection is present to confirm response to therapy. 1, 5
• Only 4-8% of children require oral antibiotic rescue therapy for persistent symptoms when topical fluoroquinolones are used correctly. 1
• Refer to ENT if:
  • No improvement after 48-72 hours of appropriate therapy
  • Perforation persists beyond 3 months
  • Vertigo or significant hearing loss is present
  • Perforation contacts the malleus 1, 4, 3

Common Pitfalls to Avoid

• Never irrigate the ear canal when perforation is present, as this causes middle ear infection, vertigo, or ototoxicity. 1
• Never prescribe neomycin-containing drops (including Cortisporin), as the FDA label explicitly warns against use with perforated tympanic membranes due to permanent hearing loss risk. 7
• Do not assume all "antibiotic ear drops" are safe—only fluoroquinolones lack ototoxicity with middle ear exposure. 1, 5
• Avoid cerumenolytics or mineral oil when the tympanic membrane is not intact. 1

Special Considerations for At-Risk Children

• Children with Down syndrome or craniofacial malformations may require more aggressive monitoring, though specific evidence for perforation management in these populations is limited. 8
• All children in reviewed studies healed spontaneously, suggesting excellent prognosis with conservative management in the pediatric population. 6