Pediatric emergency medicine trisk 816

increased risk of inserting things in their ears. Objects can cause trauma to the
TM including possible perforation, and can disrupt the sensitive bony (medial)
portion of the EAC, increasing the risk of infection.

Clinical Considerations
Clinical Recognition
Patients may present following a witnessed insertion of objects, the presence of
otorrhea, decreased hearing, or pain. In some cases, patients are asymptomatic
and the foreign body is found incidentally during physical examination. Objects
may include stones, beads, foam, wax, paper, insects, or organic materials such as
beans and popcorn kernels. 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 euthanize them and stop further
movement.
Initial Assessment
The initial assessment 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 that the child remain very still to avoid advancing the foreign
body or local trauma to the canal. In addition to a handheld 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 130
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 or various
otologic forceps (e.g., bayonet or alligator) can grasp objects. Commercially
available devices (e.g., Katz extractor) are available to help remove foreign
bodies from the ear or nose. When using these devices, a catheter is advanced


behind the object, the balloon is inflated on the distal side of the object, and the
catheter is withdrawn (with the balloon inflated) to extract the object. Body
temperature water can be used to irrigate and remove objects against the TM,
provided 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
euthanized by instilling alcohol or mineral oil into the canal before attempting to
remove them, again 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, there is risk of further damage to the EAC or
TM, and procedural sedation in the ED could be considered. Removal in the ED
with sedation has the same safety profile as OR removal, potentially with lower
cost. Following successful removal, if there is excoriation or trauma to the EAC,
topical combination antibiotic and steroid otic drops should be used to prevent
otitis externa and to help decrease any inflammation. Over-the-counter pain
analgesia can be used for any minor discomfort. If the foreign body cannot be
successfully removed and there are no concerns for pain, bleeding, or infection,
patients may be referred for removal by an otolaryngologist either in an ED that
can provide procedural sedation or in a day surgery setting.

Ear Trauma
Goals of Treatment
The primary goal of treating ear trauma is to prevent cosmetic defects that could
result from the injury and 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 cartilaginous infections and lead to
worsened cosmetic appearance.
CLINICAL PEARLS AND PITFALLS
Auricular hematomas should be identified and treated promptly.
Unrecognized traumatic perforation of the TM can lead to serious
complications.
A thorough assessment of hearing including gross hearing, whisper
test, and tuning fork assessment for both conductive and sensorineural
hearing loss should be performed on all children with 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 can lead to
cartilage necrosis if not decompressed in a timely fashion. 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 clinician 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,
examination for foreign body, and evaluation for other associated injuries. The
auricle should be inspected for any externally visible deformity/injury including
lacerations or avulsions, with attention to any cartilage exposure, 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 imaging is not routinely indicated for
simple, isolated injuries. Imaging should be considered to evaluate for associated
injuries, including closed head injury or facial fractures, in the setting of
concerning symptoms or findings (see Chapters 107 Facial Trauma and 113
Neurotrauma and Head Injury Clinical Pathway at ).


Management
Lacerations should be thoroughly irrigated and the wound closed primarily in a
layered fashion. If the injury involves cartilage, then these edges must be
approximated and closed prior to repairing the cutaneous layers. 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.” In these cases, the wide incision should be made
along or within the cartilaginous folds of the auricle to fully evacuate clot or fluid
and to maximize cosmesis. Some practitioners prefer to place a compression
dressing utilizing dental rolls or petroleum gauze, while others prefer to place
“quilting” sutures through-and-through the auricle with nonabsorbable suture.

There is demonstrated safety and effectiveness for surgical management.
Patients with 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. They should be seen in 5 to 7 days by an
appropriate medical provider to remove dressings and sutures. For patients with
auricular hematoma, assessment for any reaccumulation is also important.
Although data are limited, patients who have auricular hematomas drained may
have a tenuous blood supply and, therefore, should receive a short course
(commonly 7 to 10 days) of prophylactic antibiotics. Quinolones are often
utilized as they cover routine skin flora (e.g., staphylococcus) as well as
Pseudomonas aeruginosa , and have effective penetration into cartilage.
Although there are reported risks of arthropathy with quinolones, no clinical
studies have demonstrated these findings in children. Therefore, quinolones are
felt to be the best choice in young children as well. Amoxicillin with clavulanate
is commonly recommended when there is hesitancy to use quinolones. 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.
Ears with cold thermal injury should be rapidly rewarmed and recooling should
be avoided. Hot thermal injuries should receive symptomatic care, avoiding
excessive cooling or ice in direct contact of the ear skin.

MIDDLE EAR
Current Evidence