II. Etiology

  1. Trauma
    1. Physical abuse red flag
    2. Foreign body
    3. Forceful Ear Irrigation
  2. Infection
    1. Otitis Media
    2. Acute Chronic Otitis Media
  3. Middle Ear Barotrauma (e.g. Scuba Injury)

III. Symptoms

IV. Signs

  1. Size perforation as percent of membrane
  2. Traumatic perforations often lack discharge
  3. Weber lateralizes to side of perforation

V. Management

  1. Keep ear dry
    1. No swimming
    2. Ear plugs (or cotton balls in vaseline) for showering or bathing
  2. Otolaryngology Consultation indications
    1. Most cases of TM Perforation (but only large,non-healing perforations will need surgery)
    2. Possible ossicle disruption
    3. Associated Vertigo (may be due to inner ear injury, consult within 24 hours)
  3. Antibiotics (when indicated)
    1. Indications
      1. Concurrent Otitis Media
      2. TM Perforation in a wet, contaminated environment such as seawatere (and also keep canal dry)
    2. Topical, non-ototoxic antibiotic options - 100x oral concentration (may also add oral Aminopenicillin antibiotics)
      1. Do not use Cipro HC Otic (not sterile)
      2. Avoid all cortisporin products (including suspension, per new labeling as of 2014)
      3. Combinations with steroid result in faster resolution but are much more expensive
      4. Ofloxacin 0.3% (Floxin Otic) 5 drops (10 drops if over age 12) twice daily for 7 days
      5. Ciprofloxacin ophthalmic (ciloxan drops) 4 drops twice daily for 7 days
      6. Ciprofloxacin 0.3% with Dexamethasone 0.1% (Ciprodex) 4 drops in ear twice daily for 7-10 days
      7. Ciprofloxacin 0.3% with Fluocinolone Acetonide 0.025% (Otovel) 0.25 ml vial in ear twice daily for 7 days

VI. Prognosis

  1. Usually heal well spontaneously (95% of cases) in 4-6 weeks
  2. Large or marginal perforations may require surgery

VII. References

  1. Orman and Finley in Herbert (2018) EM:Rap 18(3):14

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