Overview
There are a variety of injuries to the ear that can be seen in the pediatric population. These vary from minor lacerations of the external ear to more severe cases of traumatic injury such as temporal bone fractures. Children with ear injuries may present in the outpatient setting, such as a pediatrician or otolaryngologist’s office, or in the emergency department, depending on the nature of the otologic trauma as well as other concurring injuries. While there are many articles that summarize the management of otologic injuries in adults, few discuss the management of ear trauma specifically in children.
External ear trauma
Trauma to the external ear most commonly results from blunt force. Less often, injury is caused by penetrating trauma, nonaccidental trauma, or self-injury. These injuries often involve the external ear, including the auricle and external auditory canal only; however, some severe injuries may also involve the middle and inner ear structures. Comprehensive history and physical exam is important to determine the extent of the injury, and in some cases, diagnostic testing with audiogram or imaging may be necessary to evaluate for injuries extending beyond the external ear.
The ears are particularly susceptible to trauma given their protrusion from the face overlying a bony surface. Auricular lacerations can either be simple or complex depending on whether the injury extends into the cartilage. Simple lacerations can often be repaired using sutures with a local anesthetic, whereas complex lacerations that expose cartilage require careful reapproximation. Patients who present within 24 h of the injury should undergo repair. If the injury occurred over 24 h prior, or if there are signs of active infection, then delayed closure may be optimal. Another common laceration is a split earlobe, which can be caused by pulling at an earring through the piercing hole. Repair by a surgical subspecialist may be warranted, as there are a variety of cosmetic techniques that can be used to repair these lacerations. For all auricular laceration repairs, the contralateral ear should be used as a guide to optimize symmetry between the two ears Fig. 16.1 .
Auricular hematoma is a collection of blood between the perichondrium and cartilage of the ear. This is commonly seen in the pediatric setting of trauma, often as sports injuries. Damage to the vasculature and separation of perichondrium from the underlying cartilage can result in the development of a potential space, thereby allowing for the accumulation of blood. Auricular hematomas are diagnosed clinically from obtaining a thorough history and performing a physical exam. Diagnostic imaging is not required and typically only utilized to rule out other diagnoses. Significant pain, erythema, and swelling may be suggestive of cellulitis rather than auricular hematoma. Ultrasound can be helpful to exclude auricular abscess. Hearing is not typically affected in the setting of an isolated auricular hematoma; hearing loss in this setting should prompt imaging with either CT or MRI to evaluate for concurrent damage to middle or inner ear structures. In pediatric patients, or when the mechanism of injury is unclear, nonaccidental trauma should be considered and appropriate protocols should be employed to determine if the patient is at further risk for harm Fig. 16.2 .
Treatment for auricular hematoma includes drainage with needle aspiration, incision and drainage, or drainage with placement of bolster, depending on the size and duration of the hematoma. The procedure can be performed at the bedside or in the operating room depending on provider and patient comfort. Drainage should occur as soon as possible after the injury. Untreated or repeated auricular hematomas allow for persistent fluid accumulation within the perichondrium and can result in a swollen and misfolded appearance of the auricle, commonly referred to as “cauliflower ear.” In persistent or severe cases, surgical reconstruction with otoplasty may be warranted to improve the cosmetic appearance of the ear.
Injury to the external auditory canal may be seen in isolation or in conjunction with other traumatic injuries. In children, isolated external auditory canal injury is often seen in the setting of a foreign body or use of a cotton swab causing damage to the ear canal skin. Complications may include otitis externa, and with risk of subsequent development of canal stenosis. In the context of a patient presenting with facial trauma, blood in the external auditory canal is suggestive of underlying temporal bone or mandibular fracture. Treatment is variable depending on the mechanism of injury but involves managing risk of infection in the canal, repairing underlying fractures when indicated, and preventing stenosis of the canal during the healing process.
Traumatic tympanic membrane perforation
Perforation of the tympanic membrane can be caused by several mechanisms, including infection, mechanical injury, blast, and barotrauma. Mechanical trauma to the tympanic membrane occurs due to insertion of a foreign body or instrument into the ear canal and is most commonly caused by use of a cotton swab. Although manufacturers and physicians advise against the use of cotton swabs in the ear canal, cotton swab use remains the most common cause of accidental penetrating trauma to the ear. Each year in the United States, over 12,000 children are treated in the emergency room for injury to the ear due to use of a cotton swab. These injuries most often occur at home, in young children, and in the setting of attempting to clean the ear canal. Use of cotton swabs is associated with a number of otologic complications, including tympanic membrane perforation, ossicular injury, conductive hearing loss, cerumen impaction, and otitis externa.
Blast trauma to the ear can also result in tympanic membrane perforation. This injury is more commonly seen in adult patients, particularly those who have served in the military. However, these injuries in children are likely underreported in the literature, especially from regions where access to otolaryngologists is limited. These injuries can occur in the context of warfare, domestic terrorism events, or recreational activities, including the use of fireworks. Blast injuries can cause damage to not only the middle ear but also the inner ear, and they can cause a temporary or permanent sensorineural hearing loss, as well as tinnitus or hyperacusis.
Inadequate pressure equalization between the middle ear space and the external environment can also result in tympanic membrane perforation. The Eustachian tube connects the nasopharynx with the middle ear space; when functional, it allows for exchange of air and subsequently equalizes the pressure between the two spaces. However, when pressure changes are sudden or extreme, or when Eustachian tube function is reduced or absent, traumatic perforation of the tympanic membrane can occur. Approximately 100 kPa of pressure is required to rupture the tympanic membrane. In children, otic barotrauma is most commonly seen in the setting of air travel or diving underwater, where significant changes in pressure occur over a short period of time.
The diagnosis of traumatic tympanic membrane perforation is made clinically. The perforation is often visible on otoscopic examination; however, tympanometry can be used to diagnose perforations which are small, partially healed, or anatomically positioned outside the range of otoscopic visualization. Audiometric evaluation may also be indicated to determine the degree of any hearing loss from the injury and can also be helpful as a baseline measurement to monitor for changes in hearing over time.
Management of tympanic perforations is dependent on the size of the perforation, degree of hearing loss, or development of complications, such as chronic otitis media, cholesteatoma, and mastoiditis. All patients should be instructed to keep the affected ear dry to decrease the risk of infection. Perforations that are small in size and cause minimal hearing loss may be managed conservatively with symptomatic care only, as most small traumatic perforations will heal spontaneously. For large or complicated perforations, surgical repair may be required. Tympanoplasty can be performed either via a transcanal or postauricular approach. Transcanal repair can be performed with use of either a microscope or an endoscope, which can offer a minimally invasive repair in children where transcanal surgery is not otherwise facile. A postauricular incision may be utilized if canalplasty is required for successful repair. Autologous grafts are often used in repair, including temporalis fascia, tragal or conchal cartilage or perichondrium, and split-thickness skin grafts. Cadaveric or sterile, acellular allografts can also be used. Irrespective of surgical approach or graft material, the majority of tympanoplasties result in successful closure of the perforation and improvement in hearing outcomes. In blast injuries, otolaryngologists should have a high index of suspicion for implantation-type cholesteatoma.
Ossicular injury
Injury to the ossicular chain can result directly from trauma or secondarily as a surgical complication. Primary injury to the ossicles can occur via direct pressure waves from a blast or penetrating foreign body. Indirect forces can also cause ossicular chain disruption, such as acceleration–deceleration events or blunt trauma to the head. Fig. 16.3 shows CT imaging of an incus displaced into mastoid antrum in a pediatric patient due to a motor vehicle accident. Ossicular injury is a risk when performing any middle ear surgery, which can result in either disruption of the ossicular chain or accidental removal of the ossicles. There is increased risk when removing a foreign body from the outer or middle ear space, as the object can obstruct visualization of critical structures.
