Management of Tympanic Membrane Perforation

Initial Assessment and Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends keeping the ear dry to prevent infection and using non-ototoxic topical preparations when treating associated infections, allowing for spontaneous healing in most cases 1, 2
Tympanometry can be considered if swelling or discomfort don't preclude its use, with a normal type A tracing suggesting an intact tympanic membrane 1
Avoid irrigation and pneumatic otoscopy in cases of suspected perforation as these can worsen the injury or introduce infection 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends using only non-ototoxic topical preparations when the tympanic membrane is not intact, as ototoxic preparations can cause severe hearing loss after prolonged or repetitive administration 1, 2

Novel adjuvant treatments for enhancing TM perforation repair include biomolecules to stimulate growth of perforation edges 4, 5, bioengineered scaffolds 5, and tissue-engineered myringoplasty with basic fibroblast growth factor (b-FGF) which has shown a 98.1% closure rate versus 10% with saline 5

For diabetic patients or immunocompromised individuals with ear infections, consider atraumatic cleaning with aural suctioning under microscopic guidance 1
In cases of fungal otitis externa (otomycosis) with TM perforation, topical antifungal therapy is recommended, with oral antifungals considered for refractory cases 6
Avoid ear irrigation in patients with TM perforation as this can introduce infection and cause complications 3, 7

Cartilage reconstruction provides superior structural outcomes compared to temporalis muscle fascia, with better graft integration rates and fewer postoperative perforations, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 8
The use of basic fibroblast growth factor (b-FGF) with gelatin sponge scaffold achieves a 98.1% closure rate, versus 10% with saline control, according to the American Academy of Otolaryngology-Head and Neck Surgery 8
Various bioengineered scaffolds are safe and improve healing rates, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 8

The American Academy of Otolaryngology-Head and Neck Surgery recommends avoiding the use of ototoxic ear drops, such as aminoglycosides, in patients with tympanic membrane perforation, as they can cause permanent sensorineural hearing loss 9
The American Academy of Otolaryngology-Head and Neck Surgery suggests providing adequate analgesia based on pain severity, as tympanic membrane perforation pain can be intense due to proximity of the periosteum, and recommends using acetaminophen or NSAIDs for mild to moderate pain, and combination products with oxycodone or hydrocodone for moderate to severe pain 9

The Infectious Diseases Society of America recommends systemic antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis for perforations associated with acute otitis media 10, 11, 12
The Infectious Diseases Society of America suggests using amoxicillin as first-line treatment for acute otitis media with systemic symptoms, or using β-lactamase-stable agents given current resistance patterns 10, 11, 12

Topical quinolone ear drops are recommended over systemic antibiotics for perforations with otorrhea, providing high local drug concentrations while avoiding systemic resistance (American Academy of Otolaryngology–Head and Neck Surgery). 13
When any topical therapy is indicated, quinolones remain the preferred antibiotic class (American Academy of Otolaryngology–Head and Neck Surgery). 13

Only non‑ototoxic topical preparations should be applied to a perforated tympanic membrane; aminoglycoside‑based drops can cause permanent sensorineural hearing loss with repeated use (American Academy of Otolaryngology–Head and Neck Surgery). 14
Ototoxic ear drops—including aminoglycosides and polymyxin combinations—must be avoided entirely in patients with tympanic membrane perforations (American Academy of Otolaryngology–Head and Neck Surgery). 14

In diabetic or immunocompromised individuals, atraumatic aural suction under microscopic guidance is advised instead of irrigation to reduce the risk of necrotizing otitis externa (American Academy of Otolaryngology–Head and Neck Surgery). 14

For perforations persisting beyond three months, cartilage graft reconstruction yields a higher graft‑integration rate (~92 %) compared with temporalis fascia grafts (~84 %) (American Academy of Otolaryngology–Head and Neck Surgery). 15
Tissue‑engineered repair using basic fibroblast growth factor achieves closure in ~98 % of cases, far surpassing saline control (~10 %) (American Academy of Otolaryngology–Head and Neck Surgery). 15

Technique	Success Rate
Cartilage graft reconstruction	≈ 92 %
Temporalis muscle fascia graft	≈ 84 %
Basic fibroblast growth factor (bFGF)	≈ 98 %
Saline control	≈ 10 %