Evaluation and management of middle ear trauma
- Adele Karen Evans, MD, FAAP
Adele Karen Evans, MD, FAAP
- Associate Professor of Pediatric Otorhinolaryngology
- Louisiana State University School of Medicine
- Steven D Handler, MD, MBE
Steven D Handler, MD, MBE
- Professor, Otolaryngology: Head and Neck Surgery
- University of Pennsylvania School of Medicine
- Section Editors
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The management of blunt or penetrating middle ear trauma will be reviewed here. The evaluation and management of ear barotrauma and temporal bone fractures are discussed separately. (See "Ear barotrauma" and "Skull fractures in children: Clinical manifestations, diagnosis, and management" and "Skull fractures in adults".)
Middle ear injury or injury to adjacent inner ear structures or both occurs in up to one-third of patients with severe head trauma and over one-half of patients with temporal bone basilar skull fractures [1-3]. These injuries include hemotympanum (picture 1), hearing loss, cerebrospinal fluid (CSF) fistula, otic capsule injury, and traumatic perilymphatic fistula [1-5].
Otic capsule injury is four to five times more likely if temporal bone fracture occurs with facial nerve paralysis, CSF otorrhea, or both .
Middle ear injury may also occur after direct blunt trauma to the external auditory canal (eg, hand blow to ear ["boxed ears"], fall onto the ear while water or snow skiing, motor vehicle collision, sports injury [eg, wrestling]) or penetrating trauma (eg, Q-tip, matchstick injury, gunshot wound, welding or soldering spark) [3,4,6-10].
Barotrauma with middle ear injury can occur during air travel, scuba diving, or exposure to a blast. (See "Ear barotrauma", section on 'Etiology'.)
- Ort S, Beus K, Isaacson J. Pediatric temporal bone fractures in a rural population. Otolaryngol Head Neck Surg 2004; 131:433.
- Lee D, Honrado C, Har-El G, Goldsmith A. Pediatric temporal bone fractures. Laryngoscope 1998; 108:816.
- Zimmerman WD, Ganzel TM, Windmill IM, et al. Peripheral hearing loss following head trauma in children. Laryngoscope 1993; 103:87.
- Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997; 18:188.
- Kim SH, Kazahaya K, Handler SD. Traumatic perilymphatic fistulas in children: etiology, diagnosis and management. Int J Pediatr Otorhinolaryngol 2001; 60:147.
- Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol 2005; 119:366.
- Keogh IJ, Portmann D. Drop weld thermal injuries to the middle ear. Rev Laryngol Otol Rhinol (Bord) 2009; 130:317.
- Wohlgelernter J, Gross M, Eliashar R. Traumatic perforation of tympanic membrane by cotton tipped applicator. J Trauma 2007; 62:1061.
- Lasak JM, Van Ess M, Kryzer TC, Cummings RJ. Middle ear injury through the external auditory canal: a review of 44 cases. Ear Nose Throat J 2006; 85:722, 724.
- Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. J Pediatr 2017; 186:124.
- Neuenschwander MC, Deutsch ES, Cornetta A, Willcox TO. Penetrating middle ear trauma: a report of 2 cases. Ear Nose Throat J 2005; 84:32.
- Friedland DR, Wackym PA. A critical appraisal of spontaneous perilymphatic fistulas of the inner ear. Am J Otol 1999; 20:261.
- Minor LB. Labyrinthine fistulae: pathobiology and management. Curr Opin Otolaryngol Head Neck Surg 2003; 11:340.
- Maitland CG. Perilymphatic fistula. Curr Neurol Neurosci Rep 2001; 1:486.
- Iloreta AM, Malkin BD. Facial nerve paralysis following transtympanic penetrating middle ear trauma. Ear Nose Throat J 2011; 90:510.
- Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid? Ann Emerg Med 1993; 22:718.
- Warnecke A, Averbeck T, Wurster U, et al. Diagnostic relevance of beta2-transferrin for the detection of cerebrospinal fluid fistulas. Arch Otolaryngol Head Neck Surg 2004; 130:1178.
- Johnson F, Semaan MT, Megerian CA. Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin North Am 2008; 41:597.
- Aguilar EA 3rd, Yeakley JW, Ghorayeb BY, et al. High resolution CT scan of temporal bone fractures: association of facial nerve paralysis with temporal bone fractures. Head Neck Surg 1987; 9:162.
- Evans AK, Licameli G, Brietzke S, et al. Pediatric facial nerve paralysis: patients, management and outcomes. Int J Pediatr Otorhinolaryngol 2005; 69:1521.
- Fitzgerald DC. Head trauma: hearing loss and dizziness. J Trauma 1996; 40:488.
- Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforations of the tympanic membrane. Clin Otolaryngol 2008; 33:420.
- Yetiser S, Hidir Y, Birkent H, et al. Traumatic ossicular dislocations: etiology and management. Am J Otolaryngol 2008; 29:31.
- Orji FT, Agu CC. Patterns of hearing loss in tympanic membrane perforation resulting from physical blow to the ear: a prospective controlled cohort study. Clin Otolaryngol 2009; 34:526.
- Weber PC, Bluestone CD, Perez B. Outcome of hearing and vertigo after surgery for congenital perilymphatic fistula in children. Am J Otolaryngol 2003; 24:138.
- Greywoode JD, Ho HH, Artz GJ, Heffelfinger RN. Management of traumatic facial nerve injuries. Facial Plast Surg 2010; 26:511.
- CLINICAL ANATOMY
- Middle ear
- Adjacent structures
- CLINICAL FEATURES
- Physical examination
- - Findings of middle ear injury
- - Facial nerve function
- Ancillary studies
- - Evaluation of ear or nose drainage
- - Tests of hearing
- - Computed tomography
- INDICATIONS FOR OTOLARYNGOLOGY CONSULTATION OR REFERRAL
- Initial stabilization
- Minimal hearing loss
- Marked hearing loss
- Child and elder protection
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS