PANCE Blueprint EENT (7%)

Tympanic membrane perforation (ReelDx)


TM Perforation

9 m/o with fussiness and decreased oral intake

Patient will present as → a 9-month-old female with nasal congestion and cough is brought to your clinic by her mother who reports that the child is very fussy, has been tugging at her right ear, and refuses to eat. On physical exam, you note copious green/yellow nasal discharge and right-sided otorrhea. An otoscopic exam reveals a significant amount of clear/white discharge obstructing your view. With careful examination, you are able to observe a ruptured right tympanic membrane. 

Traumatic perforation of the TM causes sudden severe pain sometimes followed by bleeding from the ear, hearing loss, and tinnitus.

  • Most common causes are infection, direct trauma, or barotrauma
  • The only class of antibiotics that are non-ototoxic are Floxin drops and should be used if you are going to be prescribing drops with a perforated TM.
  • Most TM perforations are nonurgent and do not require immediate evaluation by an otolaryngologist. Often, these can be managed as an outpatient with drops and pain control to decrease inflammation; ENT follow-up in a few days to a week.
  • A significant portion of TM perforations heal spontaneously without intervention because of the TM’s regenerative abilities.
  • Most are uncomplicated with minimal hearing loss (<40 dB) and lack vestibular complaints.
  • Observation of >3 months is a feasible option in select patients with uncomplicated, small perforations.
  • Debate exists over dry-ear precautions. But conservatively, patients should avoid getting water into the external auditory canal and into the middle ear space. Typical showering is less of an issue, but swimming in rivers/swimming pools should be avoided until the perforation has healed.
    • For patients who participate in water sports as a part of daily life, such as swimmers and divers, repair is recommended to provide the patient a “safe ear.”
    • Because there is a connection from the outer ear to the middle ear, dry ear precautions are needed to prevent a nidus of infection such as using a cotton ball in the ear during showers and gentle hairdryer use over-ear if water enters the ear canal.

Diagnosis is based on otoscopy

Patients with small isolated tympanic membrane perforation <25 percent in size and minimal hearing loss (<40 dB, decreased perception of whisper or minor asymmetry):

  • Water precautions, topical antibiotic otic drops x 5-7 days, audiometry within 24 hours if not previously obtained, and follow-up with their primary care provider in four weeks to ensure that the perforation is closed and the hearing deficit has been resolved
    • The only class of antibiotics that are non-ototoxic are Floxin drops and should be used if you are going to be prescribing drops with a perforated TM
  • Surgery may be needed for perforations persisting > 2 mo, disruption of the ossicular chain, or injuries affecting the inner ear

Patients with significant middle ear trauma and hearing loss ≥40 dB, vestibular signs (eg, nystagmus, vomiting, ataxia), findings that indicate basilar skull fracture, or facial nerve injury should undergo emergency evaluation by an otolaryngologist within 48 hours of injury

Question 1
A 13 year-old presents with pain in his right ear and loss of hearing since yesterday. He has never had an episode like this before. On exam vital signs are T- 38°C P- 70/minute R- 18/minute BP- 90/60 mmHg. Neck is supple, without lymphadenopathy. Right tympanic membrane is not visible; the canal is swollen, with small amount of exudate and blood noted. There is tenderness of the external ear, especially with gentle traction of the tragus. Left tympanic membrane is normal, and the canal is clear. Oropharynx is normal. Which of the following is the most appropriate topical treatment for this patient?
Tobramycin otic drops
Preparations containing aminoglycosides should be avoided in ears where the integrity of the tympanic membrane cannot be confirmed
Erythromycin solution
Erythromycin solution is not used to treat otitis externa.
Offloxacin otic drops
Gentamicin drops
Gentamicin drops are not used in the treatment of otitis externa.
Question 1 Explanation: 
The ideal antibiotic regimen should have coverage against the most common pathogens, S. aureus and P. aeruginosa. The fluoroquinolones ofloxacin and ciprofloxacin provide excellent coverage against both pathogens. In addition, the suspension is safe to use in suspected cases of tympanic perforation.
There is 1 question to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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