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Otologic Trauma, Emergency Medicine

Basics

Description

- Blunt trauma: - Contact sports such as wrestling - Motorcycle helmets

- Signs of basilar skull fracture: - Hemotympanum or serous effusion - Retroauricular hematoma (battle sign) - CSF otorrhea or rhinorrhea - Peripheral facial nerve paralysis

- Weber test: Place a struck tuning fork to center of forehead: - Normal: Equal sound perception in both ears - Abnormal due to neurosensory loss: Patient will have decreased sound perception in the impaired ear - Abnormal due to conductive loss: Increased sound perception in the impaired ear

- Tetanus prophylaxis if necessary - Specific injury types: - Auricular hematoma: Drainage imperative to reapproximate perichondrium to cartilage to prevent cartilage necrosis, ideally within 72 hr; however, no clearly defined best treatment - Antistaphylococcal antibiotics for 7 " “10 days - Aspiration: Preferred alternative if clot not yet formed; use 18G " “20G needle for aspiration milk hematoma until totally evacuated; apply pressure dressing - Incision and drainage: More effective with larger and/or clotted hematomas; incise along curvature of pinna with no. 15 scalpel, evacuate, and irrigate; apply pressure dressing - Vaseline gauze pressure dressing: Place to fill crevices of pinna; place over and behind pinna; wrap soft gauze firmly around head - Alternative pressure dressing: Suture dental rolls into place over incised area - If patient has 2nd presentation due to reaccumulation, hematoma should be reaspirated and a wick placed for drainage

- Laceration: - Prophylactic antibiotics are controversial but for human and animal bites treat with amoxicillin " “clavulanate - Clean and debride wound, anesthetize as necessary - Superficial abrasions: Clean, dress with antibiotic ointment - Simple lacerations: 5 or 6 monofilament nylon or polypropylene suture, then pressure dressing; may use absorbable suture to avoid having to bend ear for suture removal - Exposed auricular cartilage: Carefully debride jagged edges; completely cover cartilage to prevent perichondritis; can remove small amount of cartilage to allow skin coverage; approximate cartilage 1st with absorbable sutures at major landmarks; include anterior and posterior perichondrium in stitch - Avulsions: - <2 cm total avulsions may be used as graft and survive - >2 cm: Consult or urgently refer to otolaryngologist or plastic surgeon

Pinna

  • Ear cartilage has no blood supply and isnutritionally dependent on perichondrium
  • Hematomas often disrupt perichondrium and cartilageCan lead to:IschemiaPerichondritisNecrosisCauliflower ear
  • Penetrating injuries or bite wounds may lead to infection of cartilage

Middle Ear

  • Air-space cavity containing ossicles; susceptible to injuries disrupting pressure (blast, diving)
  • Bordered by medial cranial fossa (including temporal and mastoid bones)
  • Traumatic fractures can lead to CSF leak (otorrhea/rhinorhea)May disrupt enclosed vestibular system
  • Facial nerve passes through cavity " ”injury to cavity may cause peripheral nerve paralysis

Etiology

  • Blunt trauma:Contact sports such as wrestlingMotorcycle helmets
  • Penetrating trauma such as tympanic membrane (TM) perforation from cotton swabs
  • Human or animal bites
  • Blast injury
  • Lightning injury:TM and ossicular disruptions occur in 50% of lightning strikes
  • Chemical exposure
  • Thermal injury
  • Diving injuries:Inner ear barotraumaTM rupture

Consider nonaccidental trauma ‚

Diagnosis

Signs and Symptoms

  • Severe ear pain
  • Bleeding
  • Signs of auricular deformity:EdemaHematoma:Bluish, fluctuant, or doughy swelling of auricleLacerationAmputationLoss of contour of the pinna
  • Signs of middle ear trauma:Decreased hearing:Partial loss suggests TM ruptureComplete loss suggests injuries to ossicles or inner earTinnitusMiddle ear effusion or canal drainagePeripheral facial nerve paralysisVestibular symptoms, i.e., nystagmus or vertigo:May also result from inner ear injury
  • Signs of basilar skull fracture:Hemotympanum or serous effusionRetroauricular hematoma (battle sign)CSF otorrhea or rhinorrheaPeripheral facial nerve paralysis

History

  • Mechanism
  • Associated injuries
  • Past otologic history
  • Medications and allergies

Physical Exam

  • Head
  • Cranial nerves
  • Vascular structures
  • Pinna
  • External ear canal
  • TM
  • Hearing
  • Consider the Weber and the Rinne test to evaluate for conductive hearing loss due to TM rupture or perforation:Rinne test: Place a struck tuning fork to mastoid tip, hold until patient no longer hears ringing, then place fork near external auditory opening:Normal: Patient still hears ringing; air conduction > bone conductionAbnormal: No sound heard; air conduction < bone conduction; implies a conductive hearing lossWeber test: Place a struck tuning fork to center of forehead:Normal: Equal sound perception in both earsAbnormal due to neurosensory loss: Patient will have decreased sound perception in the impaired earAbnormal due to conductive loss: Increased sound perception in the impaired ear
  • Be sure to evaluate for concomitant injuries

Diagnosis Tests & Interpretation

Lab

Wound culture if signs of infection ‚

Imaging

  • Consider head and/or facial CT to evaluate for intracranial injury or bone fracture
  • Consider CT temporal bone without contrast if evidence of serious middle ear injury

Differential Diagnosis

  • Infection
  • Hemangioma
  • Foreign body in ear

Treatment

Pre-Hospital

If auricle is amputated, wrap in moist gauze and place in plastic bag ‚

Initial Stabilization/Therapy

  • Check ABCs; full trauma evaluation; resuscitation as appropriate
  • Sterile dressing to injured site

Ed Treatment/Procedures

  • All injury types:Anesthesia:Local anesthesia via nerve block to auriculotemporal branch of mandibular nerve, lesser occipital nerve, greater auricular nerve, and auricular branch of vagus nerve; use 1% lidocaine or 0.25% marcaineAlternative: Inject ring of anesthetic around base of pinna
  • Tetanus prophylaxis if necessary
  • Specific injury types:Auricular hematoma: Drainage imperative to reapproximate perichondrium to cartilage to prevent cartilage necrosis, ideally within 72 hr; however, no clearly defined best treatmentAntistaphylococcal antibiotics for 7 " “10 daysAspiration: Preferred alternative if clot not yet formed; use 18G " “20G needle for aspiration milk hematoma until totally evacuated; apply pressure dressingIncision and drainage: More effective with larger and/or clotted hematomas; incise along curvature of pinna with no. 15 scalpel, evacuate, and irrigate; apply pressure dressingVaseline gauze pressure dressing: Place to fill crevices of pinna; place over and behind pinna; wrap soft gauze firmly around headAlternative pressure dressing: Suture dental rolls into place over incised areaIf patient has 2nd presentation due to reaccumulation, hematoma should be reaspirated and a wick placed for drainage
  • Laceration:Prophylactic antibiotics are controversial but for human and animal bites treat with amoxicillin " “clavulanateClean and debride wound, anesthetize as necessarySuperficial abrasions: Clean, dress with antibiotic ointmentSimple lacerations: 5 or 6 monofilament nylon or polypropylene suture, then pressure dressing; may use absorbable suture to avoid having to bend ear for suture removalExposed auricular cartilage: Carefully debride jagged edges; completely cover cartilage to prevent perichondritis; can remove small amount of cartilage to allow skin coverage; approximate cartilage 1st with absorbable sutures at major landmarks; include anterior and posterior perichondrium in stitchAvulsions:<2 cm total avulsions may be used as graft and survive>2 cm: Consult or urgently refer to otolaryngologist or plastic surgeon

Medication

  • Amoxicillin " “clavulanate: Adults: 875/125 mg PO BID (peds: 40 mg/kg/d PO BID)
  • Dicloxacillin: 250 " “500 mg PO QID (peds: 30 " “50 mg/kg/d PO div. q6h)

Follow-Up

Disposition

Admission Criteria

  • Concomitant serious traumatic injuries
  • Need for IV antibiotics
  • Immunosuppressed persons with serious infections, perichondritis, or chondritis

Discharge Criteria

  • Able to tolerate oral antibiotics
  • Able to arrange close follow-up

Follow-Up Recommendations

  • Follow up wound suture repair in 5 days
  • Follow up hematomas in 24 hr to evaluate for reaccumulation

Additional Reading

  • Ghanem ‚ T, Rasamny ‚ JK, Park ‚ SS. Rethinking auricular trauma. Laryngoscope. 2005;115:1251 " “1255.
  • Jones ‚ SE, Mahendran ‚ S. Interventions for acute auricular haematoma. Cochrane Database Syst Rev. 2004;(2):CD004166.
  • McKay ‚ MP, Mayersak ‚ RJ. Facial trauma. In: Marx ‚ J, Hockberger ‚ R, Walls ‚ R, eds. Rosens Emergency Medicine. 7th ed. St. Louis, MO: Mosby; 2009.
  • Riviello ‚ RJ, Brown ‚ NA. Otolaryngologic procedures. In: Rogers ‚ JR, Hedges ‚ J, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, PA: WB Saunders; 2009.

See Also (Topic, Algorithm, Electronic Media Element)

  • Barotrauma
  • Tympanic Membrane Perforation

Codes

ICD9

  • 380.00 Perichondritis of pinna, unspecified
  • 920 Contusion of face, scalp, and neck except eye(s)
  • 959.09 Injury of face and neck
  • 738.7 Cauliflower ear
  • 872.61 Open wound of ear drum, without mention of complication

ICD10

  • H61.009 Unspecified perichondritis of external ear, unspecified ear
  • S00.439A Contusion of unspecified ear, initial encounter
  • S09.91XA Unspecified injury of ear, initial encounter
  • M95.10 Cauliflower ear, unspecified ear
  • S09.20XA Traumatic rupture of unspecified ear drum, initial encounter

SNOMED

  • 285059008 Injury of external ear (disorder)
  • 50228009 Contusion of ear (disorder)
  • 37600001 perichondritis (disorder)
  • 28072004 Cauliflower ear (disorder)
  • 307497002 Traumatic tympanic membrane perforation