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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.