How should a ruptured tympanic membrane be managed?

Management of Ruptured Tympanic Membrane

Immediate Management

Keep the ear completely dry and avoid any ear irrigation or pneumatic otoscopy, as these can worsen injury or introduce infection. 1

• Use earplugs or petroleum jelly-coated cotton balls when showering 1
• Avoid swimming until the perforation has healed 2, 1
• Never irrigate the ear canal when perforation is present or suspected, as this can cause middle ear infection, vertigo, or ototoxicity 2

Pain Management

Administer analgesics on a scheduled basis rather than as-needed, as pain prevention is easier than treatment. 3

• Use acetaminophen or NSAIDs for mild to moderate pain 3
• Use opioid combinations for severe pain, which may occur due to the highly sensitive periosteum of the underlying bone 3

Examination and Cleaning

Perform aural toilet (gentle suctioning) when the ear canal is obstructed by debris to enhance delivery of topical medications if infection is present. 3

• Use tissue spears to absorb secretions and facilitate entry of topical drops 2
• Avoid cotton-tipped applicators as they may cause further trauma or leave behind fibers 2

Topical Antibiotic Treatment (Only If Infection Present)

Use fluoroquinolone eardrops (ofloxacin or ciprofloxacin-dexamethasone) as the ONLY safe topical antibiotics for ruptured tympanic membranes. 2, 1

• Ciprofloxacin-dexamethasone combination is first-line due to superior clinical efficacy and cost-effectiveness 2
• These achieve drug concentrations 100-1000 times higher than systemic antibiotics at the infection site 2
• Limit treatment to a single course of no more than 10 days to prevent otomycosis 2

Critical Contraindications

Absolutely avoid aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations) as they cause severe permanent sensorineural hearing loss after exposure through perforations. 2, 1

• Even when you cannot visualize the tympanic membrane due to canal edema or debris, assume a perforation may be present and avoid neomycin 2
• Avoid alcohol-containing drops as alcohol in the middle ear space is both painful and potentially ototoxic 2

Proper Administration Technique

• Warm the bottle in hand for 1-2 minutes before instillation 2
• Have the patient lie with the affected ear upward 2
• Pump the tragus 4 times after instillation 2
• Maintain the position for 5 minutes to facilitate middle ear penetration 2

When to Add Systemic Antibiotics

Reserve systemic antibiotics for specific indications only—they should not be prescribed as initial therapy for uncomplicated perforations. 2

Add systemic antibiotics when:

• Cellulitis of the pinna or adjacent skin is present 2
• Signs of severe infection or extension beyond the ear canal exist 2
• Patient has diabetes or is immunocompromised 2
• Topical therapy fails after 48-72 hours despite adequate drug delivery 2
• Concurrent acute otitis media is present 3

Follow-Up Protocol

Reassess within 48-72 hours if the patient fails to respond to initial therapy to confirm diagnosis and exclude other causes. 3, 2

• Obtain baseline audiometry at least 6 weeks post-injury to document hearing status after initial inflammation has resolved 1
• Repeat audiometry is indicated if symptoms persist beyond 6-8 weeks or if surgical repair is being considered 1

Surgical Referral Indications

Refer to otolaryngology for perforations that fail to heal spontaneously by 90 days (3 months). 1

Urgent referral is needed for:

• History of vertigo, nausea, and vomiting with conductive hearing loss >30 dB, suggesting ossicular chain disruption 4
• Profound sensorineural hearing loss, which may signify inner ear nerve damage 4
• Perforation in contact with the malleus, which is associated with lower frequency of spontaneous closure 5

Expected Outcomes

• Most perforations (67-88%) heal spontaneously without complications 5, 6
• All children typically demonstrate complete spontaneous recovery 7
• Tissue-engineered myringoplasty achieves 98.1% closure rates versus 10% with conservative management alone for perforations requiring surgery 1
• If a sign of spontaneous closure is observed within 6 months following injury, long-term observation may be viable even beyond 6 months 5

Common Pitfalls to Avoid

• Never use cerumenolytics or mineral oil when the tympanic membrane is not intact 2
• Do not assume the tympanic membrane is intact if you cannot visualize it—treat as perforated until proven otherwise 2
• If a patient tastes ear drops, this is a sign of perforation and they should inform their doctor immediately 2
• Delayed treatment beyond 90 days increases risk of permanent hearing loss and structural complications including retraction pockets, ossicular erosion, adhesive atelectasis, or cholesteatoma 1