Which ear drops are appropriate for a patient with a perforated (ruptured) tympanic membrane and signs of middle‑ear infection?

Ear Drops for Ruptured Tympanic Membrane

Use only non-ototoxic fluoroquinolone ear drops—specifically ofloxacin 0.3% or ciprofloxacin 0.2%—when the tympanic membrane is perforated or uncertain. 1, 2, 3

Why Fluoroquinolones Are Mandatory

Aminoglycoside-containing drops (neomycin/polymyxin B combinations) are absolutely contraindicated because they cause documented inner-ear toxicity when they reach the middle ear through a perforation. 1, 2 Ofloxacin is the only FDA-approved topical antibiotic explicitly safe for perforated tympanic membranes. 2, 3, 4

The fluoroquinolones achieve drug concentrations 100–1,000 times higher at the infection site than oral antibiotics, explaining their superior 77–96% cure rates versus 30–67% for systemic therapy. 2

Specific Dosing Regimen

For ofloxacin 0.3% otic solution (the preferred agent): 3

• Adults and children ≥13 years: 10 drops (0.5 mL) into the affected ear once daily for 7 days
• Children 6 months to 13 years: 5 drops (0.25 mL) into the affected ear once daily for 7 days
• With tympanostomy tubes (ages 1–12 years): 5 drops twice daily for 10 days
• Chronic suppurative otitis media (≥12 years): 10 drops twice daily for 14 days

Essential Pre-Treatment Step

Before any drops, perform aural toilet to remove debris, cerumen, and inflammatory material—medication cannot penetrate through obstructing material. 1, 2 Use gentle suction or dry mopping; avoid irrigation in diabetic or immunocompromised patients because it can trigger necrotizing otitis externa. 1, 2

Proper Administration Technique

1. Warm the bottle in your hand for 1–2 minutes to prevent dizziness 3
2. Have the patient lie with the affected ear upward 2, 3
3. Instill the prescribed number of drops to fill the canal 2, 3
4. Pump the tragus 4 times by pushing inward to facilitate middle-ear penetration 3
5. Maintain this position for 5 minutes 2, 3

When to Add Systemic Antibiotics

Reserve oral fluoroquinolones (ciprofloxacin 500 mg twice daily) for: 1, 2

• Extension beyond the ear canal (periauricular cellulitis)
• Diabetes or immunocompromised status
• Severe canal edema preventing adequate topical delivery
• No improvement after 48–72 hours of appropriate topical therapy

Topical therapy alone remains first-line even with perforation; 20–40% of patients inappropriately receive oral antibiotics despite inferior outcomes. 2

Critical Pitfalls to Avoid

• Never use neomycin/polymyxin B drops when tympanic membrane integrity is uncertain—this causes ototoxicity 1, 2, 5
• Avoid ciprofloxacin + dexamethasone combinations in perforations—the steroid significantly delays healing (5.5-fold increased odds of persistent perforation at 4 weeks) 6, 7
• Do not skip aural toilet—debris blocks medication penetration 1, 2
• Do not prescribe oral antibiotics as initial therapy for uncomplicated cases 1, 2

Expected Course

Pain typically improves within 48–72 hours of starting topical therapy. 1, 2 Reassess if no improvement occurs within this timeframe—common causes of failure include inadequate drug delivery, poor adherence, fungal co-infection, or incorrect diagnosis. 1, 2 Complete the full 7-day course even if symptoms resolve early to prevent relapse. 2

Ofloxacin demonstrates no ototoxicity in animal or human studies, unlike aminoglycosides, making it the definitive choice for perforated membranes. 4, 5