Management of pediatric otologic trauma

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.