Traumatic ear

1. TRAUMATIC EAR
By Marei Matroud
Supervised by dr Hussein Al mattari

2. I. Auricular hematoma
 collection of blood between the perichondrium and
the cartilage of the pinna.
 typically occur as a result of the auricle being
pulled or subjected to blunt trauma
 If untreated it can lead to chondritis, abscess
formation, and ‘cauliflower ear’ deformity
 Treated initially with aspiration with a wide-bored
needle and application of compressive head
bandage to reduce recurrence.

3.  If hematoma recurs after aspitration , or size of
hematoma is greater than 1/3rd of the size of the pinna,
then incision and drainage (under local or general
anaesthetic) is advised, with the addition of through-
and-through sutures over dental rolls, to prevent re-
accumulation of the hematoma, and a compressive head
bandage.
 Antibiotics are required if: Signs of infection (red,
painful, swollen, tender ear). Previous
aspiration/drainage attempts. and/or Delay in
presentation.

4. II. Lacerations
 They are repaired as early as possible. The
perichondrium is stitched with absorbable sutures.
 Special care is taken to prevent stripping of
perichondrium from cartilage for fear of avascular
necrosis.
 Skin is closed with fine non absorbable sutures
 Broad-spectrum antibiotics are given for 1 week.

5. III. Avulsion of Pinna
 When pinna is still attached to the head by a
small pedicle of skin, primary reattachment
should be considered and it is usually
successful.
 Completely avulsed pinna can be re implanted
in selected cases by the microvascular
techniques

6. IV. Thermal injuries to the pinna
Frostbite
 occurs when exposure to low temperatures causes
freezing of the skin and underlying tissues .
 The injury varies between erythema and oedema, bullae
formation, necrosis of skin and subcutaneous tissue, and
complete necrosis with loss of the affected part
 Treatment is by gentle and gradual rewarming with
moist cotton pledgets at a temperature of 38–42

7. Burn
 First-degree burns can be treated with supportive
measures :
• cold compresses
• appropriate analgesia / antibiotics
 Second- and third-degree burns (blistering and
full thickness, respectively) can be treated with ;
• antibiotic cover (including anti-pseudomonas);
• surgical debridement (as necessary).
• Reconstructive surgery

8. It takes one or more of the following forms
 Tympanic-membrane injury (perforation) .
 Ossicular injury (discontinuity, fixation) .
 Tympanic-cavity injury (barotraumas) .
Tympanic-membrane injury (perforation)
1.

9. 2. Direct trauma from a foreign body (cotton-bud).
3. Skull-base fracture, when the fracture line involves the tympanic ring.
 Signs and symptoms
 Otalgia.
 Hearing loss
 ± Tinnitus. ± Dizziness.
 ± Otorrhoea (bloody initially, purulent if infection supervenes. Also CSF
otorrhoea in temporal bone fracture).

10. toscope examination will reveal a pars tensa
perforation with bleeding edges (if recent injury).
Treatment
 1st assess and manage any associated head injury.
 If there is a relevant history , Do a Hearing assessment
using pure tone audiometry to confirm conductive
hearing loss ( possibility of ossicular injury ) if
sensory-neural loss suspect temporal bone fracture
 If otorhea, Collect a sample for ß2-transferrin
analysis To roll out CSF leak

11.  ~95% of Traumatic tympanic membrane (TM) perforations heal by 6
weeks after injury
 Keep the ear dry and treat concurrent infection if present
 If fail to heal within 3 months then consider myringoplasty
Ossicular discontinuity
 loss of normal alignment between the three middle ear ossicles.
 Location
most common : incudostapedial joint separation* / incudomallelar joint
separation
less common : dislocation of the incus
Rare : stapedovestibular dislocation / ossicular fracture

12.  Causes
Iatrogenic : middle ear surgery
Non iatrogenic : blast explosion , fracture temporal bone
 Clinical picture
H/O trauma
hearing loss
Tinnitus , vertigo
 Audiology shows Conductive hearing-loss (air–bone gap >50dB HL)
with a high type A tympanogram.

13.  Computed tomography (for dx and to R/O any associated TB fracture )
incudomallear joint separation
axial images: the ice cream scoop (head of malleus) appears falling off the
cone (body and short process of incus)
coronal images: broken heart sign
incudostapedial joint separation
long and lenticular process of incus are laterally displaced away from the
head of the stapes
 These injuries are treated by hearing aids or by ossiculoplasty.

14. The ice cream scoop appears
falling off the coneThe broken heart sign

15. The long process of the incus is displaced
anteriorly to the stapes suprastructure
secondary to traumatic incudostapedial
luxation
3D CT diagnosis of traumatic
incudostapedial joint separation

16. Tympanic cavity injury (Barotrauma)
 Tissue injury caused by a change in pressure that compresses or expands
gas contained in body structures
 the middle ear is a non compressible gas-filled space and subjected to
the effects of Boyle’s law. With increasing pressure, the volume of the
gas in the middle ear reduces proportionately and With decreasing
pressure, the volume of the gas in the middle ear increase
proportionately in both cases the volume must be equalized by
equalizing techniques

17. • If equalization is not performed, when the pressure increase the
volume of the middle ear gas is reduced to the point that the tympanic
membrane is retracted severely and fluid or blood (or both) is secreted
into the middle ear, reducing the volume and equalizing the pressure.
Alternately, the tympanic membrane may rupture .
• Increasing cerebrospinal fluid ,fluid pressure then transmitted to inner
ear via cochlear aqueduct, which further increases pressure differential
between labyrinthine fluid and ME space and causes outward bulging
and rupture of RW (Explosive injury)

18. when the pressure decrease ,The volume of air within the middle ear
space increases , if the middle ear is not ventilated via the eustachian
tube, there will be pain and possible rupture of the tympanic membrane
into the external ear canal .
Low inner ear further increases pressure differential between labyrinthine
fluid and ME space so RW pushes inwards and can rupture ( Implosive
injury )

19. Signs and symptoms
 Otalgia (severe).
 Hearing loss (conductive in middle ear barotrauma but in severe cases
with inner ear sensory-neural hearing loss can occur).
 Tinnitus. Dizziness.
 Tympanic membrane may be injected, retracted, with evidence of a
middle ear effusion, or haemotympanum or perforation
 Treatment of middle ear barotrauma includes ;
oral decongestants, short-term decongestant nasal sprays .
 appropriate antibiotics if secondary infection is present

20.  Otoinflation with Valsalva maneuver
 If fail to resolve , the middle-ear effusion is treated with myringotomy
with or without grommet insertion
 If a perforated TM fails to heal within 3 months then consider
myringoplasty

21.  Treatment of inner ear barotraumas includes
bed rest with the head of the bed elevated, anti-vertiginous medication,
steroids and avoiding coughing, sneezing, and straining.
Audiograms should be performed daily, and if there is improvement,
continue nonsurgical treatment.
Most patients recover spontaneously, but if the hearing loss and vertigo
persist or worsen after 4–5 days, surgical exploration with repair of the
fistula is recommended.

22.  According to the direction of the fracture line in
relation to the long axisof the temporal bone, it can
be classified into:
1) Longitudinal (70–80%)
2) Transverse (10–20%)
3) Mixed (10%).
Longitudinal (70–80%)
 Fracture line along the temporal bone longitudinal
axis, extending from the squamous portion of the
temporal bone, medially along the external auditory
canal into the roof of the middle-ear cleft and then
into the petrous apex

23.  The mechanism of the injury is : a lateral blow to the side of the
head.
 Symptoms usually related to the middle ear
Transverse (10–20%)
 Fracture line lies across the longitudinal axis, Runs across the
petrous. Starts at foramen magnum or jugular foramen towards the
foramen Spinosum .
 The mechanism of the injury is a blow to the front or back of the
skull.
 Symptoms usually related to the inner ear

25. Otic capsule involvement
 Other classifications have been proposed as
being more clinically relevant, specifically
focusing on whether or not the otic capsule
is involved . Involvement of the otic
capsule is a predictor of more serious
complications
• facial nerve paralysis (2-5x as likely)
• cerebrospinal fluid leak (4-8x as likely)
• sensorineural hearing loss (7-25x as likely)
• epidural hematoma and subarachnoid
hemorrhage

26.  Signs and symptoms
1) Hearing loss can be:
 Conductive hearing loss due to middle-ear effusion, blood in the
external canal or ossicular damage.
 Sensory-neural hearing loss is more common in the transverse fractures
and can be total.
2) Dizziness is common but mainly temporary.

27. 3) CSF leak into the middle ear occurs if the tegmen
and the middle cranial fossa dura were breached
 CSF otorrhoea if there is a disruption of the
tympanic membrane.
 CSF otorhinorrhoea if the drainage of CSF occurs
via the Eustachian tube into the nasopharynx/nose
(more common in the transverse fractures).
4) Facial nerve paralysis
Lower motor neuron type.
More common in transverse fractures.

28.  On the examination , the external ear
may show :
• Local hematoma/ bruising of the skin
 Battle sign : post-auricular bruising .
 Raccoon sign : periorbital bruising .
• EAC lacerations /
• TM perforation and if possible, careful micro
suction of blood clots in ear canal

29.  Neurological examination with special attention to the facial nerves
Investigations
 Pure-tone audiogram ( SNHL with otic capsule violating # and CHL
with otic capsule sparing fractures )
 If CSF leak , collect a sample for ß2-transferrin analysis
 CT scan of skull base and temporal bone will delineate the fracture
line and involved structures .

32. Management
 Manage any associated head injuries
 Facial paralysis: Management analogous to Bell’s palsy
 Medical: High-dose steroids (prednisone 1 mg/kg)
 Surgical:
 Consider decompression for patients with immediate complete
paralysis and >90 % neuronal degeneration on electroneuronography
within 2 weeks of onset (similar to Bell’s palsy indications)
 If no hearing, perform translabyrinthine exploration; if hearing still
present, combined middle cranial fossa/trans mastoid exploration.

33. Cerebrospinal fluid leak
 Temporal bone fractures are the most common cause of orogenic leaks
 Majority of leaks caused by T-bone fractures close within 1–2 weeks,
initially bedrest, head of bed elevation, avoid straining, acetazolamide
 Give prophylactic antibiotics if leak present > 1 week (increased meningitis
risk);
 consider surgical closure if leak present beyond this time
 a Small defect <1 cm consider trans mastoid repair
A Large defects multiple, involving tegmen tympani (difficult to plug from
below due to the presence of ossicles) consider middle fossa or combined
approach

34. Case scenario I
A 17-year-old teenager presented with an increasingly
painful left ear swelling of 2 days duration.
1) Describe the findings.
red swelling of superior part of the left pinna
2) Give two differential .
1-Auricular hematoma 2-Auricular abscess
3) List potential complications that can occur.
septicemia , perichondritis and cauliflower ear.

35. Case scenario I
4) You are asked to perform pinna block for 70 kg adult with no history of
drug allergy what is volume of 1% lidocaine that you could safely use
The safe dose is 3 x70 =210 mg
1ml of 1% lidocaine solution contains 10 mg of lidocaine
10 mg ~ 1 ml
210mg ~ X ml
X = 210/10 = 21 ml
The safe dose of lidocaine is 3 mg /kg

37. Case scenario II
A 23-year-old woman came to the ER with a
history of trauma to her left ear while cleaning it
using cotton sticks
1) Describe the findings.
Slit shaped TM perforation with blood in
the EAC
2) Give two management plans
1. Conservative with analgesia and an advice to
keep her ear dry in hope of a spontaneous
healing will takeplace
2. Surgery myringoplasty

38.  References
• Oxford Specialist handbook Otolaryngology and Head and Neck Surgery 1st
edition 2009
• Current diagnosis & Treatment in Otolaryngology—Head & Neck Surgery
3rd edition . 2012
• Diploma in Otolaryngology Head and Neck Surgery Part 2 Revision Guide 1st
edition .2012
• Diseases of Ear, Nose and Throat & Head and Neck Surgery 7th edition . 2016
• https://radiopaedia.org/