Does a Ruptured Eardrum Require Emergency Treatment?
A ruptured tympanic membrane does not require emergency treatment in most cases, as the majority heal spontaneously with conservative management including keeping the ear dry and using non-ototoxic topical antibiotics if infection is present. 1, 2
When Emergency or Urgent Referral IS Required
You must refer urgently to otolaryngology if any of these red flags are present:
- Vertigo, nausea, or vomiting suggesting ossicular chain disruption or inner ear damage 3
- Profound sensorineural hearing loss (>30 dB conductive loss) indicating possible nerve damage 3
- Cellulitis of the pinna or adjacent skin requiring systemic antibiotics 1, 2
- Signs of cholesteatoma (unsafe perforation with progressive bone destruction) 4
- Severe infection with extension beyond the ear canal 1, 2
Initial Conservative Management (Appropriate for Most Cases)
Most traumatic and inflammatory perforations heal spontaneously within 2-3 weeks to 2 months without intervention. 4, 5, 6
Immediate Ear Protection Measures
- Keep the ear completely dry—use ear plugs or cotton balls coated with petroleum jelly when showering 1, 2
- Avoid swimming until the perforation has healed 1
- Never irrigate the ear canal as this causes middle ear infection, vertigo, or ototoxicity 1, 2
- Avoid cotton-tipped applicators which cause further trauma 1, 2
Topical Antibiotic Therapy (If Infection Present)
Use only fluoroquinolone eardrops—these are the ONLY safe antibiotics for perforated eardrums. 1, 2
- First-line: Ciprofloxacin-dexamethasone combination drops (superior efficacy to antibiotics alone) 1, 2
- Alternative: Ofloxacin drops 1, 2
- Clean the ear canal first by suctioning debris under visualization to enhance drug delivery 1, 2
- Limit treatment to ≤10 days to prevent otomycosis 1, 2
Proper instillation technique: Warm bottle in hand 1-2 minutes, patient lies with affected ear up, instill drops, pump tragus 4 times, maintain position for 5 minutes 1
Absolutely Contraindicated Medications
NEVER use aminoglycoside-containing drops (neomycin, gentamicin, polymyxin B-neomycin combinations)—these cause permanent sensorineural hearing loss after exposure through perforations. 1, 2, 7
Also avoid:
- Alcohol-containing drops (painful and ototoxic) 1, 2
- Cerumenolytics or mineral oil 1, 2
- Any ear irrigation 1, 2
Pain Management
Perforation pain can be intense due to periosteum proximity: 2, 7
- Mild to moderate pain: Acetaminophen or NSAIDs 2, 7
- Moderate to severe pain: Combination products with oxycodone or hydrocodone 2, 7
When to Add Systemic Antibiotics
Reserve oral antibiotics only for these specific indications: 1, 2
- Cellulitis of pinna or adjacent skin 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 or extension outside ear canal 1, 2
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) 2, 7
Second choice: Amoxicillin-clavulanate for β-lactamase-producing organisms 2, 7
Follow-Up and Reassessment
- Reassess at 48-72 hours if no response to initial therapy 1, 2
- Refer to otolaryngology if perforation does not heal within 1 month 3
- All children in this study healed spontaneously without surgery 5
- Only 4-8% of patients require oral antibiotic rescue therapy 1
Critical Warning Sign
If the patient tastes the ear drops, this confirms perforation—immediately switch to non-ototoxic fluoroquinolone preparation. 1, 2