ENT TRAUMA

MICHELLE L. NIESCIERENKO, MD AND GI SOO LEE, MD, EdM

GOALS OF EMERGENCY THERAPY

General Goals

Trauma to ear, nose, and throat can range from minor to life-threatening, which can be secondary to airway compromise, or in some cases blood loss. Beyond the immediate risk, secondary complications can include infection of vital structures or compromise of vasculature secondary to damage. The goal of emergency care is immediate recognition of injuries that may result in airway or hemodynamic compromise and prompt involvement of an otolaryngologist or pediatric surgeon. Clinicians should balance invasive diagnostic testing with the goal of limiting secondary complications resulting from the injury, which include infection, hematoma, or cosmetic deformity.

RELATED CHAPTERS

TRAUMA TO THE EAR

Ear Foreign Body

Goals of Treatment

The goal of treatment is to remove the foreign body as early after it is recognized as possible. Early removal allows for the easiest possible extraction reducing risk of trauma to the external canal or tympanic membrane (TM). Removal of the foreign body prevents infection, damage to the TM and can prevent hearing compromise.

CLINICAL PEARLS AND PITFALLS

• Examine the ear with caution to avoid advancing the object further into the canal.

• Be sure to check other orifices for additional foreign bodies.

• Disk batteries should be removed as soon as they are identified to avoid rapid tissue destruction.

• Kill insects in the external auditory canal (EAC) using mineral oil or alcohol before attempting removal.

• Attempting to irrigate biologic foreign bodies can result in them swelling and becoming more firmly lodged in the auditory canal.

Current Evidence

Foreign objects in the EAC are a common occurrence in children with nearly 10,000 visits annually. Objects can cause trauma to the TM or to the sensitive canal especially the bony (medial) portion of the EAC with risk for infection or TM perforation.

Clinical Considerations

Clinical Recognition

Patients may present following a witnessed insertion of objects, the presence of ear drainage, decreased hearing, or pain. In some cases, patients are asymptomatic and the foreign body is found incidentally during physical examination. Objects can be stones, beads, foam, wax, paper, insects, beans, or other food items. Ear foreign bodies are very common in children, especially those under 5 years of age.

Triage

The majority of children are well appearing, asymptomatic, or in mild/moderate pain. Those with any bleeding from the ear or hearing loss require prompt evaluation. Live insect foreign bodies are disconcerting and mineral oil or alcohol should be immediately instilled in the canal to stop movement.

Initial Assessment

The initial assessment, history and physical examination should be focused on determining any history of object insertion, ear pain or ear drainage as well as what type of object the foreign body might be. This information is important for the removal plan.

Examination of the ear canal requires the child remain very still to avoid advancing the foreign body or local trauma to the canal. In addition to a hand held otoscope, a nasal speculum can be used to gently displace the tragus, and allow better visualization of the canal. As with the otoscope, care must be taken when inserting the tines of the nasal speculum to prevent further insertion or impaction of the foreign body or injury to the canal skin.

Management

Treatment focuses on safe removal of the foreign body (see Chapter 141 Procedures, Section on Ear Foreign Body Removal). In the emergency setting for the cooperative child, an ear curette can be used to scoop objects out, various otologic forceps (e.g., bayonette or alligator) can grasp objects. Commercially available devices (e.g., Katz extractor) are available to help remove foreign bodies from the ear or nose. These devices are designed to advance the catheter behind the object, inflate the balloon, and then pull it out of the canal. Body temperature water can be used to irrigate and remove objects against the TM, but only if the TM is intact. Avoid irrigating organic objects (e.g., food, paper) as they can swell and become further lodged in the EAC. Insects should be killed by instilling alcohol or mineral oil into the canal before attempting to remove them, provided the TM is intact. To reduce pain for these procedures a topical anesthetic can be applied in advance. If the child is uncooperative with the procedure risking further damage to the EAC or TM, procedural sedation in the emergency setting could be considered.

Following successful removal, if there is excoriation or trauma to the EAC topical otic antibiotic drops should be used to prevent otitis externa in the discharged patient. Over-the-counter pain relievers can be used for any minor discomfort. If the foreign body cannot be successfully removed, patients may be referred for removal by an otolaryngologist in a day surgery setting, provided there are no concerns for pain, bleeding, or infection.

Ear Trauma

Goals of Treatment

The primary goal of treating ear trauma is to prevent hearing loss, which is associated with lifelong disability. In addition, optimal management of ear trauma reduces local infection risk, which if left untreated could result in invasive bacterial infection, and can lead to worsened cosmetic appearance.

CLINICAL PEARLS AND PITFALLS

• Auricular hematomas should be identified and treated immediately.

• Unrecognized traumatic perforation of the TM can lead to serious complications.

• Thorough hearing assessment on children including gross hearing, whisper test, and tuning fork assessment for sensorineural hearing loss should be done for all ear injuries.

EXTERNAL EAR

Current Evidence

Injury to the external ear can include laceration to the skin, soft tissue, or cartilage, as well as hematoma with risk of cartilage necrosis. The cartilage of the ear is nourished and oxygenated by diffusion via the perichondrium. With an auricular hematoma, bleeding avulses the perichondrial layer off the cartilage as the blood collects between them. This separation of the perichondrium leads to cartilage necrosis. In addition to blunt or sharp trauma, the external ears are also susceptible to thermal injuries including both burn and frostbite.

Clinical Considerations

Clinical Recognition

Injuries to the external ear can manifest as laceration, ecchymosis, or hematoma. Thermal injury may present with bullous or peeling skin. Most commonly, there is a reported history of trauma or symptoms of pain or bleeding that prompts the emergency physician to recognize the injury. However, unwitnessed or asymptomatic injuries may also be identified during examination.

Triage

Any child with an external ear injury associated with serious trauma, active bleeding, new hearing loss, or neurologic symptoms should be evaluated emergently. Most children will present with mild to moderate discomfort without associated symptoms and can be seen urgently.

Initial Assessment

The initial assessment should focus on the mechanism and severity of the injury, where there is concern for foreign body, and the risk of other associated injuries. The ear should be inspected for any externally visible deformity/injury including lacerations, with attention to any cartilaginous laceration, ecchymosis, or hematoma. Note that isolated ecchymosis to the external ear canal without other signs of injury or with an inconsistent mechanism of injury should raise suspicion for nonaccidental trauma. Diagnostic testing is not routinely indicated for simple, isolated injuries. Imaging should be considered to evaluate for associated injuries, including closed head injury, in the setting of concerning symptoms or findings (see Chapter 89 Head Trauma).

Management

Lacerations should be repaired, with a layered repair if the ear cartilage is involved, including the ear lobe. Hematomas should be drained and a pressure dressing applied to prevent accumulation. Prompt drainage reduces the risk of permanent external ear deformity often referred to as “cauliflower ear.” Ears with cold thermal injury should be rapidly rewarmed and avoid recooling. Hot thermal injuries should receive symptomatic care, avoiding excessive cooling or ice in direct contact of the ear skin. Patients with isolated minor traumatic ear injury who are discharged home should be encouraged to keep ear dressings in place to avoid infection, bleeding, or reaccumulation of hematomas. The ears should be protected from further injury and exposure until fully healed. Although data are limited, patients who have required auricular hematoma drainage may have a tenuous blood supply and therefore should receive a short course (commonly 7 to 10 days) of prophylactic antibiotics. In adolescents, a quinolone is recommended to cover for routine skin flora such as staphylococcus as well as Pseudomonas aeruginosa. Quinolones are also favored based on their effective penetration into cartilage. In younger children, antibiotic selection is less clear. Amoxicillin with clavulanate is commonly recommended, though others support the use of quinolones in this age group as well given the added Pseudomonas coverage. Although there are reported risks of arthropathy with quinolones, no clinical studies have demonstrated these findings in children. Even with empiric antibiotics, close monitoring for signs of chondritis including fever, erythema, or purulent drainage is important, which should prompt admission for intravenous antibiotic therapy.

MIDDLE EAR

Current Evidence

Middle ear injury is caused by barotrauma (airplane or deep water pressure including swimming pools), forced air into the ear (e.g., slap injury), or from direct contact (e.g., wave or foreign body insertion). All three mechanisms can result in TM rupture and associated injury to middle ear structures. The ossicles can be dislocated or fractured causing conductive hearing loss. Injury to the oval or round window can lead to perilymph fistula. Barotrauma is exacerbated in the child with eustachian tube dysfunction resulting in blood vessel engorgement and risk of bleeding or serous effusion into the middle ear. Because the facial nerve traverses through the middle ear, injury resulting in facial paresis is potentially associated with middle ear injuries.

Clinical Considerations

Clinical Recognition

Clinical recognition of injury occurs from identifying mechanisms consistent with middle ear injury including barotrauma, slap of air or water, or foreign object. Patients may be asymptomatic or complain of ear pain or drainage. Other symptoms may include sudden onset vertigo, nystagmus, or sensorineural hearing loss related to injury of the stapes or oval window.

Triage

At triage these patients are generally not ill appearing, although differentiation of vertigo related to middle ear injury versus posterior fossa or neurologic etiology is important.

Initial Assessment

History should focus on the mechanism of injury and any associated symptoms with detailed review of neurologic symptoms. The TM should be carefully examined for perforations. Assess the function of the facial nerve for associated injury. Hearing assessment should be done on all children with concern for a middle ear injury.

Management

Imaging is often not indicated unless the mechanism is severe enough to warrant assessment for closed head injury. Perforations with associated vertigo, nystagmus, tinnitus, or hearing loss should be immediately referred to otolaryngology. Perforations with active drainage should be treated with topical antibiotics for 5 days to help minimize infection and wash away otorrhea or bleeding. Patients with clear fluid otorrhea that may represent CSF leak, or those with vertigo or other symptoms suggestive of perilymph fistula should be evaluated by an otolaryngologist before topical antibiotics are instilled. Certain antibiotic drops will be painful due to particular ingredients or pH of the antibiotic preparation. For example, CiproHC is likely to cause burning pain, while Ciprodex is not. Cortisporin should be avoided as the neomycin may contribute to sensorineural hearing loss. Middle ear bleeding or effusions can be treated with oral antibiotics to prevent infection and generally spontaneously resolve within 3 weeks. It is critical that discharged patients with perforations follow-up for reexamination by an otolaryngologist to ensure proper healing.

INNER EAR

Current Evidence

Concussive injuries, especially with associated temporal bone fracture, can disrupt the intracochlear membrane. Children with certain bony anomalies of the inner ear, including semicircular canal dehiscence syndrome and enlarged vestibular aqueducts (EVA), collectively known as third-window lesions, are susceptible to acute sensorineural hearing loss changes with mild head trauma. Noise-induced trauma can cause also damage to the inner ear causing SNHL. Acutely, loud blasts from explosions can cause sudden loss of hearing; this is typically less common in children given their pattern of exposure.

Clinical Considerations

Related posts:

Ataxia Cyanosis Pain: Earache Oligomenorrhea Tachycardia Pain: Chest

Stay updated, free articles. Join our Telegram channel

Join