Author: Dr Imran Hajat / Editor: Charlotte Davies / Codes: EC6, EP5, MaC2, SLO1, SLO4, SLO5, TC5, TC6, TP10 / Published: 26/01/2021

… A bite-size guide to ear trauma in the ED

Please note: within this post, the term ‘ear’ has been used for familiarity with clinicians who may not be confident with the anatomical terms of the area. The word ‘ear’ is used to refer to the anatomical area of the external ear, which includes the auricle (or pinna) and external auditory canal, up to the tympanic membrane.

Ear trauma is a common presentation to the Emergency Department. Whilst generally simple to manage, the consequences of ear trauma have the potential to impact patients’ day-to-day lives significantly1. Mismanagement of ear trauma can lead to cartilaginous necrosis of the ears and affect the wearing of glasses, masks and headsets, as well as patients’ general aesthetic appearance and mental wellbeing. Arguably, the most important aspects in caring for patients with ear trauma are centred around the initial management in the ED and recognising an appropriate referral to specialist teams. This post is intended to provide a bite-sized guide to assist doctors and other practitioners in the effective triage, management and referral of patients presenting to the Emergency Department with ear trauma.

A picture showing the inner ear anatomy starting at the external auditory canal, moving anticlockwise to the tympanic membrane, the tympanic canal, the round window, the eustacian tube, cochlear, cochlear nerve, vestibular nerve, semicircular canals, stapes, incus, malleus.

Figure 1: Anatomy of the human ear. “File:Anatomy of the Human Ear.svg” by Lars Chittka; Axel Brockmann is licensed under CC BY 2.5

Due to the nature of ear trauma often coexisting amongst other injuries, the assumption is made that patients are first assessed using a structured A-to-E approach following appropriate guidelines (e.g. ATLS) and first treated for more urgent or life-threatening concerns. Once these are resolved, do not forget the head and especially the ear as within a small anatomical space lie a number of important and delicate structures (organs of hearing and balance, as well as the emergence of a number of cranial nerves through the skull base) therefore, injuries which appear trivial at first glance can have potentially serious consequences. Always ensure appropriate imaging is requested and reported and if in any doubt, contact your local ENT and/or trauma teams for advice.

Below is a list of common presentations to the ED which may fall under the umbrella term of ‘ear trauma’:

  • Piercings – complications and infections
  • Auricular/pinna haematoma and ‘cauliflower ears’
  • Lacerations and bites
  • High impact head trauma (road traffic collision, assault)
  • Traumatic tympanic membrane perforation
  • Foreign body trauma (hearing aids, cotton buds, toys)

To assist with the assessment of a patient presenting with a traumatic injury to the ear, injuries can be loosely classified based on the impact force (high or low-impact force), and mechanism (blunt or sharp trauma). In a high-impact injury, careful consideration must be given to the surrounding structures (temporal bone, cranial nerves) with thorough examination and imaging where appropriate. After thinking about the impact force and mechanism of the injury, it may be useful to ask yourself the following questions:

  1. Are there any red flags (see below)?
  2. Is there a loss of shape or structure to part, or all of the ear?
  3. Is the skin broken, bleeding, or contaminated?
  4. Is there suspected bone or cartilaginous involvement of the injury?
  5. Is the patient likely to remain compliant throughout the treatment, healing and follow-up process? Generally, patients who may be unable to sit still or keep their ear clean and dry following treatment (confused patients, children, and patients with learning disabilities) may require early ENT input.

Ear Trauma red flags:

  • Suspected CSF leak: clear fluid (may be bloodstained) discharge from external auditory canal or nostrils
  • Altered or fluctuating consciousness, focal neurological or cranial nerve signs
  • Uncontrollable bleeding
  • Suspected or confirmed fracture of any bones of the skull

If the answer to any of the above questions is ‘yes’, it is a good idea to involve your local ENT and/or maxillofacial teams for advice. If any red flags are present, urgent ENT advice/assessment is recommended.

Picture of an ear above the RCEMLearning logo with red flags signs in a red box and yellow flag signs in a yellow box.

It takes a fairly significant amount of force to damage an ear, and always be suspicious of non-accidental earing in children. Ear bruising is an NAI red flag, and you should always be thorough in your assessment and refer any suspicions.

Lacerations and bites 

Simple lacerations and bites involving the epidermis and/or dermis of the ear can be cleaned and glued or held together using steri-strips2. Complex injuries to the ear which require sutures, lacerations with jagged edges, and all injuries involving the subcutaneous tissue or cartilage should be discussed with your local ENT team. Wounds to the ear which appear soiled or contaminated should also be discussed with ENT, as they may require more extensive washout and/or debridement. Immunisation boosters, as well as topical and oral antibiotic cover should be considered and, if appropriate, prescribed in line with local antibiotic guidelines.

full-thickness pinna laceration

Figure 2: full-thickness pinna laceration following an industrial accident, for urgent ENT/plastics referral. “849 – 30 yo worker – ear laceration” by iem-student.org is licensed under CC BY-NC-SA 2.0

Burns

Burns where the skin is blistered or broken should be discussed with local ENT and/or burns teams3. All burns due to chemical, radiation or cold exposure should also be discussed. Simple superficial burns (usually caused by hair-straighteners/curlers) can be treated as any other burn in the ED3.

Piercings

All issues resulting from ear piercings should be discussed with ENT due to the risk of abscess/haematoma formation and cartilaginous necrosis. Usually, urgent specialist assessment and management is required4. The exception to this is those pesky earing backs that get embedded in the ear lobe – in a compliant patient, these can be removed in ED using an auricular block. Some departments have been known to put topical local anaesthetic on the ear lobe, and then make a small incision to release the earing, but an auricular block is much better.

Auricular Haematoma and ‘cauliflower ear’

Picture of a man with a big lumpy ear called a cauliflower ear.

Figure 3: an untreated pinna/auricular haematoma or ‘cauliflower ear’, same-day referral to ENT for incision and drainage . “File:Shawn’s cauliflower ear.jpg” by MartialArtsNomad.com is licensed under CC BY 2.0

Auricular/pinna haematomas are usually caused by high-impact blunt force trauma to the auricle (commonly contact-sports injuries and assaults) but can also be caused by piercings4,5. The force of the injury shears blood vessels in the perichondrium, which bleed to form a fluctuant or boggy swelling. If left untreated, reduced blood supply to the perichondrium can cause avascular necrosis of the underlying cartilage, ultimately leading to a loss in shape of the auricle (also known as “cauliflower ear”) and increasing the chance of infection. If recognised and referred early, definitive treatment usually involves surgical incision and drainage. All suspected pinna haematomas should be referred to ENT the same day.

Needle aspiration fails in about 75% of cases. Drainage of an auricular haematoma was a specifically mentioned skill on the 2015 EM syllabus, but we think this is better done by ENT. It involves incising along an anatomic crease (to avoid a scar), using forceps to encourage all of the haematoma out, putting a drain in, and then a dressing for compression.

Foreign body

For foreign bodies that can be fully visualized with an otoscope, removal with forceps may be attempted in the ED, taking care not to damage the external auditory canal and tympanic membrane6. Any foreign body that cannot be fully visualized, has caused bleeding or tympanic membrane perforation, or resulted in inflammation or infection of the surrounding tissues should be discussed with ENT. It is worth noting that repeated failed attempts to remove an object from the external auditory canal can cause bleeding and swelling to the area, which can make further removal attempts more difficult and affect patient confidence. It is worth involving ENT early for any foreign body which is not easily removed. Patients with button batteries, or any objects which have the potential to secrete irritant or corrosive fluid into the external auditory canal must be discussed with ENT as a matter of urgency. It is worth noting that patient compliance, especially in paediatric patients, is paramount in the removal of foreign bodies. Taking the time to create a tidy, quiet environment, building a rapport, and clearly explaining the procedure and equipment to the patient may just reward you with a shiny, wax-covered piece of lego!

We’ve covered this in a lot more detail in our “Stuck in the Ear” RCEMLearning blog.

It is not unusual for clinicians to face anxieties when managing anatomical areas, such as the ear, which are unfamiliar to them. Hopefully this post has helped demonstrate that, for the most part, ear trauma can be quick, easy and satisfying to treat in the ED, with the majority of patients seeing substantial progress or complete resolution of their symptoms in a couple of days. Maintaining a structured approach to your assessment, involving specialist teams early, and ensuring adequate analgesia and antibiotic cover are all paramount in the effective management of patients presenting with ear trauma.

Useful websites:

https://entsho.com/: A great website for anyone interested in ENT. Content ranges from the absolute basics of managing ENT patients in the ED, to full, step-by-step breakdowns of complex operations and easy-to-digest guidelines for the management of common ENT problems.

https://www.entuk.org/: Useful website for clear, easy to access guidelines. Especially useful guidelines relating to COVID-19, recommended PPE, advice surrounding AGPs, ENT examination and procedures. Relevant recent updates include changes to recommended tonsillitis and quinsy pathways during the COVID-19 pandemic, management of COVID-19 anosmia, and management of epistaxis in the ED during COVID-19.

Dr Imran Hajat, SHO ED, Queen Elizabeth Hospital, Woolwich, London, ENT/Head and Neck Surgery, Guys & St Thomas Hospital, London, ENT, University Hospital Lewisham, London

RCEMLearning Links:
Stuck in the Ear
Ear Disease
Otitis Externa SAQ 
Non-accidental injury induction update

References:

  1. Steffen A, Klaiber S, Katzbach R, Nitsch S, Frenzel H, Weerda H. Epidemiology of auricular trauma. Handchir Mikrochir Plast Chir. 2007 Apr;39(2):98-102.
  2. https://www.uptodate.com/contents/assessment-and-management-of-auricle-ear-lacerations Michelle Malloy, Hollander Judd E (accessed 21/01/21)
  3. https://www.who.int/surgery/publications/Burns_management.pdf (accessed 20/01/21)
  4. Krogmann RJ, Jamal Z, King KC. Auricular Hematoma. [Updated 2020 Dec 16]. In: StatPearls
  5. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear.Facial Plast Surg. 2010;26(6):451
  6. Dance D, eat al. REMOVAL OF EAR CANAL FOREIGN BODIES IN CHILDREN: WHAT CAN GO WRONG AND WHEN TO REFER. BCMJ, vol. 51 , No. 1 , January February 2009