Management of Perforated Tympanic Membrane with Otitis Externa

Initial Assessment and Treatment Considerations

The American Academy of Otolaryngology-Head and Neck Surgery recommends carefully assessing for modifying factors that affect management, including non-intact tympanic membrane, diabetes, immunocompromised state, and prior radiotherapy, when treating a patient with a perforated tympanic membrane and otitis externa 3, 4
The American Academy of Otolaryngology-Head and Neck Surgery advises against irrigation and pneumatic otoscopy in cases of suspected perforation, as these can worsen the injury or introduce infection, in patients with a perforated tympanic membrane 2
Gentle aural toilet (cleaning) using suction under microscopic guidance is recommended, especially for diabetic or immunocompromised patients with a perforated tympanic membrane 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends using only non-ototoxic topical preparations when the tympanic membrane is not intact to prevent potential sensorineural hearing loss in patients with a perforated tympanic membrane 1, 4

Consider placing a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized, and use compressed cellulose wicks (preferred) or ribbon gauze rather than cotton balls, in patients with a perforated tympanic membrane 5
Remove the wick once ear canal edema subsides, typically within 24 hours to a few days, in patients with a perforated tympanic membrane 5

Assess pain severity and provide appropriate analgesic treatment, as pain from otitis externa can be intense, and consider using acetaminophen or nonsteroidal anti-inflammatory drugs for mild to moderate pain, and fixed combinations with opioids for severe pain, in patients with a perforated tympanic membrane 4, 6

Suspect fungal otitis externa (otomycosis) if the patient fails to respond to initial topical antibiotic therapy, and consider topical antifungal therapy, in patients with a perforated tympanic membrane 7, 6

Reassess the patient within 48-72 hours if they fail to respond to the initial therapeutic option, in patients with a perforated tympanic membrane 1, 4

Avoid irrigation in patients with perforated tympanic membranes, and never use potentially ototoxic preparations (containing aminoglycosides like neomycin or gentamicin) in patients with perforated tympanic membranes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 1
Use caution with aural toilet in diabetic or immunocompromised patients, and consider atraumatic cleaning with aural suctioning under microscopic guidance, in patients with a perforated tympanic membrane 5