Evaluation and management of middle ear trauma
- Adele Karen Evans, MD, FAAP
Adele Karen Evans, MD, FAAP
- Associate Professor, Pediatric Otolaryngology - Head and Neck Surgery
- Wake Forest 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
- Associate Professor of Pediatrics
- 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
Middle ear trauma arises from blunt or penetrating head injury, direct ear trauma, or barotrauma caused by events such as blast injury, air travel, or scuba diving. Pediatric and adult injuries require the same steps in management. Patients with isolated small tympanic membrane perforations may be managed with antibiotic ear drops for contaminated wounds, water precautions (keeping water out of the middle ear), and reevaluation to ensure that the perforation has healed. Patients with significant hearing loss (≥40 dB), vertigo, nystagmus, ataxia, or facial nerve injury warrant prompt evaluation by an otolaryngologist (ENT surgeon) or other specialist as indicated (eg, neurosurgeon for head injury).
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" 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) [3,4,6-9].
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- Lee D, Honrado C, Har-El G, Goldsmith A. Pediatric temporal bone fractures. Laryngoscope 1998; 108:816.
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- 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.
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- 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.
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- 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.
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- 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
- Clinical findings