What is the treatment for a ruptured tympanic membrane in a toddler following acute otitis media (AOM)?

From the Guidelines

For a toddler with a tympanic membrane rupture following otitis media, the primary treatment approach is typically watchful waiting, as most perforations heal spontaneously within 1-3 months. This approach is supported by the American Academy of Otolaryngology-Head and Neck Surgery, as stated in the 2017 guideline 1. The use of watchful waiting is also recommended in other guidelines, such as the one published in 2016 1, which emphasizes the importance of managing the child with otitis media with effusion who is not at risk with watchful waiting for 3 months.

When managing a toddler with a tympanic membrane rupture, it is essential to:

• Keep the ear dry by placing cotton balls coated with petroleum jelly in the outer ear during bathing
• Avoid swimming until healing is complete
• Manage pain with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) as needed
• Use antibiotic ear drops such as ofloxacin (5 drops twice daily for 7-10 days) if there is active drainage
• Avoid oral antibiotics unless there are signs of ongoing infection

It is crucial to follow up with a healthcare provider in 2-3 weeks to confirm healing is progressing. If the perforation persists beyond 3 months, referral to an ENT specialist may be necessary to consider surgical repair (myringoplasty) 1. The reason most perforations heal on their own is that the tympanic membrane has excellent regenerative properties, particularly in children, and the cessation of pressure and drainage from resolving otitis media creates favorable conditions for healing.

Key considerations in managing a toddler with a tympanic membrane rupture include:

• Monitoring for signs of infection or other complications
• Providing guidance on ear care and protection
• Ensuring regular follow-up with a healthcare provider to assess healing progress
• Considering referral to an ENT specialist if the perforation persists or if there are concerns about hearing or speech development.

From the Research

Treatment for Tympanic Membrane Rupture in Toddler Following Otitis Media

• The treatment for tympanic membrane rupture in a toddler following otitis media is a complex issue, and the available evidence suggests that the use of antibiotics may have a limited effect on the outcome 2, 3.
• A study published in 2023 found that antibiotics do not reduce pain at 24 hours, but result in almost a third fewer children having pain at two to three days, and likely result in two-thirds fewer having pain at 10 to 12 days 2.
• Another study published in 2020 found that the number needed to treat to reduce pain varied from seven to 28, and that adverse events were seen in every 13th patient treated with antibiotics 3.
• Topical corticosteroids, such as dexamethasone, may hinder tympanic membrane healing in a chinchilla model of acute otitis media 4.
• Tympanoplasty in children is a straightforward procedure with a good success rate, but the definition of successful tympanoplasty varies, and factors such as age, size of perforation, technique used, presence or absence of otorrhoea, eustachian tube function, and status of the contralateral ear may influence the success rate 5.
• A prospective evaluation of the aetiology of acute otitis media with spontaneous tympanic membrane perforation found that non-typeable Haemophilus influenzae was the most common pathogen, and that children with co-infections had significantly more frequent recurrent acute otitis media 6.

Management of Tympanic Membrane Rupture

• The management of tympanic membrane rupture in a toddler following otitis media should focus on relieving pain and preventing complications, rather than solely on promoting healing of the tympanic membrane 2, 3.
• An expectant observational approach may be justified for most children with mild disease in high-income countries, with a focus on adequate analgesia and monitoring for signs of complications 2.
• The use of antibiotics should be weighed against the possible harms, and should only be considered in cases where the benefits outweigh the risks 2, 3.
• Further research is needed to clarify the effect of antibiotics on the outcome of tympanic membrane rupture in toddlers following otitis media, and to determine the best approach to management 2, 3.