Pediatric emergency medicine trisk 3265 3265

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