Basics
Description
Pinna
- Ear cartilage has no blood supply and isnutritionally dependent on perichondrium
- Hematomas often disrupt perichondrium and cartilage
- Can lead to:
- Ischemia
- Perichondritis
- Necrosis
- Cauliflower 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 wrestling
- Motorcycle 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 barotrauma
- TM rupture
Consider nonaccidental trauma ‚
Diagnosis
Signs and Symptoms
- Severe ear pain
- Bleeding
- Signs of auricular deformity:
- Edema
- Hematoma:
- Bluish, fluctuant, or doughy swelling of auricle
- Laceration
- Amputation
- Loss of contour of the pinna
- Signs of middle ear trauma:
- Decreased hearing:
- Partial loss suggests TM rupture
- Complete loss suggests injuries to ossicles or inner ear
- Tinnitus
- Middle ear effusion or canal drainage
- Peripheral facial nerve paralysis
- Vestibular symptoms, i.e., nystagmus or vertigo:
- May also result from inner ear injury
- Signs of basilar skull fracture:
- Hemotympanum or serous effusion
- Retroauricular hematoma (battle sign)
- CSF otorrhea or rhinorrhea
- Peripheral 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 conduction
- Abnormal: No sound heard; air conduction < bone conduction; implies a conductive hearing loss
- 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
- 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% marcaine
- Alternative: 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 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
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