In a healthy patient without chronic ear disease, will a tympanic membrane perforation heal spontaneously or require topical or oral antibiotics?

Management of Ruptured Eardrum

Most acute traumatic tympanic membrane perforations heal spontaneously without antibiotics, but keeping the ear dry is essential to prevent infection. 1, 2

Spontaneous Healing Expectations

• The majority of acute traumatic perforations (81-95%) heal spontaneously within 2-8 weeks without intervention. 3, 4
• Healing rate is generally independent of perforation size, though larger perforations take longer to close (average 16-28 days depending on characteristics). 4
• Perforations with serosanguinous discharge heal faster (average 16 days) compared to dry perforations (average 28 days), though final healing rates are similar. 4

When Antibiotics Are Indicated

Antibiotics are only necessary when the perforation is associated with acute otitis media or signs of active infection:

• For perforations with acute otitis media: Use systemic antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis (amoxicillin as first-line). 1
• For perforations with otorrhea/drainage: Topical quinolone drops are preferred over systemic antibiotics, as they deliver concentrated medication directly to the site without promoting systemic resistance. 5, 1
• Oral antibiotics alone are NOT routinely needed for uncomplicated traumatic perforations without infection. 2, 3

Critical Management Principles

Keep the ear dry to prevent secondary infection - this is the single most important intervention. 1, 2

What to Use (If Treatment Needed):

• Only non-ototoxic topical preparations should be used when the tympanic membrane is not intact, as ototoxic agents (aminoglycosides) can cause permanent sensorineural hearing loss after prolonged or repetitive administration. 5, 1
• Topical quinolones are the preferred antibiotic choice when topical therapy is indicated. 5

What to Avoid:

• Never irrigate the ear or perform pneumatic otoscopy with suspected perforation, as this can worsen injury or introduce infection. 1
• Avoid ototoxic drops (aminoglycosides, polymyxin combinations) entirely. 5, 1

When to Refer to ENT

Immediate ENT consultation is needed for:

• Continuous pain, vertigo, or facial paralysis (alarming signs suggesting complications). 2
• Perforations that persist beyond 8-12 weeks. 2, 3
• Pre-existing tympanosclerosis (most prominent cause of healing failure). 4
• Suspected cholesteatoma or chronic suppurative otitis media. 3

Special Populations

• Diabetic or immunocompromised patients: Consider atraumatic cleaning with aural suctioning under microscopic guidance rather than irrigation, as they are at higher risk for necrotizing otitis externa. 5, 1

Surgical Options for Non-Healing Perforations

If spontaneous healing fails after 3 months of observation:

• Cartilage reconstruction provides superior outcomes (92.4% graft integration) compared to temporalis muscle fascia (84.3%). 5, 1
• Tissue-engineered approaches with basic fibroblast growth factor achieve 98.1% closure rates versus 10% with saline. 5, 1, 6