Summary
Ear injuries are usually caused by penetrating trauma, blunt trauma, or barotrauma. Common injuries include ear lacerations, which involve skin breakage; auricular hematoma, resulting in a swollen, tender ear; perichondritis, manifesting with erythema and warmth of the pinna; and tympanic membrane (TM) perforation, which causes sudden pain and, in some cases, hearing loss. For all of these conditions, the diagnosis is clinical; additional testing (e.g., audiological tests) may help establish a diagnosis or rule out complications. Management depends on the type of injury: Lacerations require wound closure, auricular hematomas must be drained, perichondritis is treated with antibiotics, and tympanic membrane perforation may heal spontaneously or require surgery. Complications include deformities and long-term hearing issues.
Approach
Open wounds [1][2]
- Apply local pressure to achieve hemostatic control.
- Provide local anesthetic or use a field block (e.g., with 1% lidocaine with epinephrine). [3][4]
- Examine wounds for foreign bodies, contamination, and exposed cartilage.
- Consult plastic surgery if there is an avulsion injury or significant loss of overlying tissue. [5]
- Proceed to acute wound management for simple ear lacerations.
After wound management or hematoma drainage, consider a bolster dressing to prevent hematoma (re)accumulation.
Avoid leaving cartilage exposed, as it can lead to chondritis.
Significant trauma [1][2]
- Assess for signs of basilar skull fracture, temporal bone fracture, and other associated injuries.
- Perform otoscopy to inspect for:
- Lacerations and foreign bodies
- TM perforation
- CSF otorrhea
- Hemotympanum
- Consult ENT and conduct audiological testing if there is evidence of hearing loss.
- Consult oromaxillofacial and/or neurosurgery if there are fractures.
- Manage auricular hematoma and TM perforation as indicated.
If tympanic membrane perforation is suspected, do not perform irrigation to clear blood or debris, as it can force contaminants into the middle ear. [6]
Ear laceration
For initial management steps, see “Approach to ear injuries.”
Wound irrigation and debridement [1][6][7]
- Clean grossly contaminated wounds.
- Avoid antiseptic solutions that may cause further damage (e.g., chlorhexidine). [8]
- Manually remove any residual foreign bodies.
- Remove necrotic cartilage or jagged skin through debridement.
Wound closure technique [1][6][8]
- Approximate wound edges and use single-layer closure if cartilage is not involved.
- If cartilage repair is needed, use absorbable sutures.
- For grossly contaminated wounds or wounds involving cartilage, consider prophylactic antibiotics with Pseudomonas coverage: e.g., ciprofloxacin (off-label). [6][8][9]
- Apply bolster dressing after repair of extensive injuries.
Follow-up
- Nonabsorbable sutures holding the bolster dressing are typically removed after 7 days. [8]
- See also “Follow-up” in “Management of open wounds.”
Auricular hematoma
Etiology [2]
- Blunt trauma: blows to the ear (e.g., during boxing or wrestling)
- Penetrating trauma: lacerations and/or perforation of the ear (e.g., due to earring misplacement, ear piercing)
Pathophysiology [2]
- Develops after blunt trauma or injury to the external ear
- Blood accumulates between the cartilage and perichondrium, which leads to cartilage separation.
Clinical features [1]
- Sudden tense, tender, and fluctuant swelling of the auricle
- Loss of normal anatomical landmarks of the anterosuperior aspect of the auricle
- Ecchymosis
If there is erythema, drainage from the ear, and hearing loss, consider an alternative diagnosis, such as auricular abscess.
Management [1][6]
- For initial management steps, see “Approach to ear injuries.”
-
Drain any tender auricular fluid collection after ear trauma.
- Standard technique: incision and drainage
- Needle aspirations are not routinely recommended. [1][9][10]
- Consult otolaryngology or plastic surgery if:
- Hematomas are > 7 days old.
- Hematomas recur after drainage.
- There are signs of cellulitis or perichondritis..
Draining an auricular hematoma prevents infection, relieves pressure, and preserves ear function and appearance. [10]
Incision and drainage
- Using a scalpel, incise skin along the natural skin folds.
- Evacuate the accumulated hematoma.
- Consider irrigating the pocket with sterile saline.
- Place bolster dressing to prevent reaccumulation.
Follow up
- Consider prophylactic antibiotics with coverage against skin flora and P. aeruginosa, e.g., ciprofloxacin (off-label). [1]
- Inspect the ear within 24 hours for reaccumulation of hematoma.
- Remove bolster dressing after a week.
Complications [1]
- Cauliflower ear: a permanent deformity of the ear caused by an untreated or inadequately drained auricular hematoma
- Perichondritis
Perichondritis of the pinna
Etiology [11]
- Piercing injury, e.g., cartilage piercing, acupuncture [12][13]
- Trauma
- Extension of otitis externa
- Most common organism: P. aeruginosa [14]
Clinical features [11][15]
- Erythema
- Swelling without fluctuance
- Tenderness
- The lobule is unaffected.
Management [11][15]
- Perichondritis is a clinical diagnosis.
- Initiate empiric antibiotics based on local protocols. [11][15][16]
- If there is evidence of an abscess or necrotic cartilage, consult ENT for surgical management.
Complications [11]
Tympanic membrane perforation
Etiology [7][17]
- Direct blow
- Ear barotrauma (e.g., blast-induced ear injury)
- Penetrating trauma, instrumentation (e.g., cotton-tipped applicators)
- Ear foreign bodies (e.g., toys, jewelry)
- Acute otitis media
Clinical features [7]
Diagnosis [7]
- Clinical diagnosis after visualizing ruptured membrane via otoscopy
- Formal audiometry may be performed if there is hearing loss.
Management [7][17]
- Management is mainly supportive; consult ENT if there is hearing loss or vertigo.
- Instruct patients to keep the ear canal dry.
- Consider topical antibiotics if there is evidence of infection (e.g., otorrhea) or remaining foreign bodies; see “Topical therapy for otitis externa” for agents and dosages.
- Tympanoplasty is reserved for perforations that do not heal spontaneously. [18]
- For cause-specific treatment, see also “Ear barotrauma,” “Acute otitis media,” and “Ear foreign body.”
Most tympanic membrane perforations heal spontaneously. [17][18]
Avoid ototoxic topical medications (e.g., aminoglycosides) in patients with tympanic membrane perforation. [19]
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