Pediatric emergency medicine trisk 817

Middle ear injury is commonly caused by barotrauma (e.g., pressure changes
during air flight 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. Ossicles can be dislocated or fractured causing conductive
hearing loss. Injury to the oval or round window can lead to a perilymph fistula
and significant vertigo. 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 should prompt a careful evaluation
for concurrent 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
insertion. Patients may be asymptomatic or complain of ear pain or drainage.
Other symptoms may include sudden onset vertigo, nystagmus, or 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 a detailed review of neurologic symptoms. The TM should be carefully
examined for perforations. Assess the function of the facial nerve given the
association with middle ear injuries. Hearing assessment should be performed on
all children with concern for a middle ear injury.
Management
Attempts at preventing airplane-associated barotrauma using saline drops for

moisturization were found to have no effect. For patients presenting with acute
injury, 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 require consultation with otolaryngology to


determine appropriate management. 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 watery otorrhea, which raises the
suspicion for CSF leak, or vertigo and other symptoms suggestive of perilymph
fistula should be evaluated by an otolaryngologist prior to any administration of
topical antibiotics. Certain antibiotic drops will be painful due to particular
ingredients or pH of the antibiotic preparation. For example, Cipro HC is likely to
cause burning pain, while Ciprodex is not. Cortisporin should be avoided as
neomycin, an aminoglycoside, can be ototoxic. Middle ear bleeding or effusions
can be treated with oral antibiotics to prevent infection and generally
spontaneously resolve within 2 to 3 weeks. It is critical that discharged patients
with perforations follow up with an otolaryngologist for reexamination.

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 (EVAs), collectively known as third-window lesions, are
susceptible to acute sensorineural hearing loss (SNHL) with even mild head
trauma. Noise-induced trauma can also damage the inner ear resulting in 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
Clinical Recognition
Inner ear injury is recognized by SNHL or the onset of vertigo in the context of
an appropriate history.
Triage
On presentation to triage, these children are not acutely ill-appearing but have a
chief complaint of sudden hearing loss, dizziness, or tinnitus.
Initial Assessment
The history should focus on the mechanism of injury, noise exposure, and the
history/progression of the hearing loss. Unless there are associated injuries, there
is generally nothing visible on physical examination for inner ear injuries.


Comprehensive audiologic testing is paramount and should be performed as soon
as possible to document the presence, nature, and extent of hearing impairment.
Tuning fork tests (i.e., Weber and Rinne) should be performed to help determine
the likely etiology for any hearing loss. To evaluate for third-window lesions, a
high-resolution CT of the temporal bones is required. Otolaryngology should be
consulted in patients with suspected inner ear injury to determine the need for
further evaluation and management. Antibiotic treatment or admission is not
routinely indicated. However, systemic corticosteroids (1 mg/kg/day of
prednisone or an equivalent) should be administered for new onset sudden SNHL.
Steroids are most effective if initiated within 24 to 48 hours of the loss.

OTHER INJURIES ASSOCIATED WITH EAR TRAUMA
Temporal Bone Fracture
Approximately 80% of temporal bone fractures are in the longitudinal orientation
and 20% are transverse. The location may help predict associated findings
including facial nerve injury and hearing loss. Longitudinal fractures are usually
extralabyrinthine and may disrupt the bony annulus of the TM causing

hemotympanum and ossicular or TM disruption. Facial nerve injury is rare with
longitudinal fractures. Transverse fractures can disrupt the otic capsule, internal
auditory canal, and the seventh and eighth cranial nerves. Approximately half of
transverse fractures have facial nerve involvement. If the fracture involves the
otic capsule, SNHL is common. Otolaryngology should be consulted for patients
with facial nerve injury for evaluation, management, and possible emergent
decompression or repair if the nerve is severed (i.e., neurorrhaphy).

CSF Otorrhea
Longitudinal fractures that rupture the TM can lead to CSF otorrhea. Transverse
fractures have a higher incidence of CSF leak, but are less likely to have otorrhea
due to an intact TM. Clear fluid in the canal should be evaluated to determine if it
is CSF. Water, tears, or home therapies can also be present. A halo of clear fluid
around any red blood cells when placed on filter paper is concerning for CSF
(i.e., halo test). Glucose testing can also be performed. However, beta-2transferrin testing is considered the most specific test to confirm CSF otorrhea.
Avoid manipulation or instrumentation when CSF otorrhea is thought to be
present, to reduce risk of meningitis through the introduction of bacteria. Patients
with CSF otorrhea are often treated with bed rest with the head of the bed


elevated. Otolaryngology and neurosurgery should be consulted. Prophylactic
antibiotics are controversial.

TRAUMA TO THE NOSE AND SINUSES
Nasal Foreign Body
Goals of Treatment
The goal of treatment is to identify a nasal foreign body, to allow prompt
removal. Safe removal of the foreign body reduces the risk of acute aspiration,
subacute local infection, sinusitis, and cartilaginous injury.
CLINICAL PEARLS AND PITFALLS

Unilateral malodorous nasal discharge should raise suspicion for a
nasal foreign body.
Care must be taken to avoid pushing or irrigating the object during
examination or removal attempts, as migration to the nasopharynx puts
the child at risk for aspiration.
Pretreatment with vasoconstrictor as well as use of a nasal speculum
can improve visualization and facilitate removal.
A known or suspected disc battery should be removed immediately to
avoid caustic injury.

Current Evidence
Foreign bodies can obstruct the nares. If the object has been present for an
extended duration, granulation tissue can form around the object. Either the tissue
or the object itself can block the ostia and increase the risk of infection.

Clinical Considerations
Clinical Recognition
Witnessed insertion or foul unilateral discharge is key to diagnosing a nasal
foreign body.
Triage
Children generally present to triage well appearing with a history consistent with
foreign body. Rarely, associated injury may result in epistaxis that should be
addressed urgently. Nasal foreign bodies can migrate posteriorly, changing a