ear trauma.pdf

EAR TRAUMA TAREK ABD EL-HAMID HAMDY PROFESSOR OF OTO-RHINO-LARYNGOLOGY AIN SHAMS UNIVERSITY  INTRODUCTION Ear trauma is a common problem in emergency medicine. The more common types of injuries are : ❑ slap to the ear, ❑ a cotton swab...

EAR TRAUMA TAREK ABD EL-HAMID HAMDY PROFESSOR OF OTO-RHINO-LARYNGOLOGY AIN SHAMS UNIVERSITY  INTRODUCTION Ear trauma is a common problem in emergency medicine. The more common types of injuries are : ❑ slap to the ear, ❑ a cotton swab injury, ❑ a severe blow to the head from falling off a bicycle or having a motor vehicle accident The ear can be injured (traumatized) in a number of different ways.: ❑ Exposure to loud noise. ❑ Blast injuries. ❑ Chemical exposures ❑ Thermal injuries ❑ Penetrating trauma ❑ Blunt trauma.  INTRODUCTION Some of the complaints that people have after a blow to the ear include: ❑ hearing loss, ❑ blocked ear, ❑ dizziness and ❑ pain. On examination of the ear: ❑ one needs to check to see if there is any blood in the canal and if the drum is intact. ❑ If there is blood in the ear canal. ❖ The more common types of injuries that cause this will be TM perforation or a fracture skull base. ❖ Along with the bleeding there may also be leakage of spinal fluid. ❖ Also one needs to check if the muscles of the face are moving with smiling and closing the eyes. ❖ If the patient is dizzy, eyes are moving very rapidly (nystagmus), this also indicates severe injury.  INTRODUCTION Treatment depends on the extent of injury. ❑ Simple perforation of the ear drum may not require any treatment at all. ❑ A basilar skull fracture will usually require several weeks of bed rest. ❑ If there are injuries to the nerves of the face or the hearing and balance center (inner ear), then emergency surgery may be needed.  Trauma to the auricle ❑ Haematoma Auris: ❑ Lacerations of the auricle. ❑ Thermal injury of the auricle Trauma to the External canal ❑ Laceration of the external canal: ❑ Longitudinal fracture of the temporal bone ❑ Foreign bodies in the external auditory meatus ❑ Traumatic tympanic membrane rupture  Trauma to the middle ear ❑ Ossicular disruption ❑ Otitic barotrauma ❑ Fracture base of the temporal bone ❑ Foreign body in middle ear ❑ Facial nerve injury Trauma to the inner ear ❑ Acoustic Trauma ❑ Transverse Fracture of The Temporal Bone ❑ Barotrauma of the inner ear. I. Trauma to the Auricle 1. HAEMATOMA AURIS: The most common complication of blunt trauma. It is collection of blood under auricular perichondrium. It is either due to: ❑ direct trauma (boxers ear) or ❑ spontaneous due to haemorrhagic blood disease or ❑ degenerative vascular disease. 1. HAEMATOMA AURIS (CONT.): TREATMENT: ❑ Aspiration: if blood still fluid or ❑ Incision and evacuation: if clotted ❑ pressure bandage & ❑ prophylactic antibiotics. ❑ If untreated: fibrosis of the clot and permanent thickening ❖ ( very ugly deformity of the ear pinna) (cauliflower ear ) 2. LACERATIONS OF THE AURICLE: Etiology: Open trauma e.g. knife injury or bite. Clinical picture: ❑ Lacerations or cut wounds of the auricle which may involve the skin with or without the underlying cartilage. ❑ In severe cases there is partial or complete avulsion of the auricle. Complication: perichondritis if infected. Treatment: Antibiotics to guard against infection, then immediate plastic repair. 3. THERMAL INJURY OF THE AURICLE: The external ear is highly susceptible to thermal injuries and progressive deep burns due to its exposed anatomical structure. The auricle is frequently injured during thermal injury of head and neck. ❑ it is covered by skin without any underlying subcutaneous tissue, ❖ it does not have significant insulation for protection. Frostbite is a thermal injury caused when tissue is exposed to sub-zero temperatures long enough for ice crystals to form in the affected tissue. ❑ Depending on the degree of tissue damage, thrombosis, ischaemia, necrosis (tissue death), gangrene and ultimately amputation may occur. II. Trauma to the External Canal 1. LACERATION OF THE EXTERNAL CANAL: Etiology: Self inflicted. Iatrogenic: Unskilled ear wash or foreign body removal. Symptoms and signs: Mild bloody otorrhoea. Laceration is seen on examination. Complication: Otitis externa. TREATMENT: Antibiotics- corticosteroid ear drops. 2. LONGITUDINAL FRACTURE OF THE TEMPORAL BONE: Longitudinal fracture of the temporal bone affecting the Middle ear, Tympanic membrane External canal. This will be discussed in detail with the middle ear trauma. 3. FOREIGN BODIES IN THE EXTERNAL AUDITORY MEATUS. Most commonly in children, less common in adults (accidentally or in mentally retarded patients). Types of foreign bodies: Animate: insects (flies or mosquito). Inanimate: ❑ Vegetable foreign bodies: as bean and pea. ✔ if you try to remove it by ear wash, it absorbs water and becomes more impacted. ❑ Non-vegetable foreign bodies as beads and buttons. 3. FOREIGN BODIES IN THE EXTERNAL AUDITORY MEATUS (CONT.). Symptoms: ❑ Asymptomatic: discovered accidentally as in small inanimate foreign bodies. ❑ Symptomatic: ✔ Hearing loss when it occludes the external canal. ✔ Tinnitus and irritation in the ear especially with animate foreign bodies. ✔ Reflex cough due to irritation of the vagus nerve branch. Signs: ❑ foreign body is seen on otoscopy. 3. FOREIGN BODIES IN THE EXTERNAL AUDITORY MEATUS (CONT.). TREATMENT: ❑ Ear wash. Contraindicated in cases of impacted or large vegetable FB WHY ???. You have to kill the insect by alcohol or oil drops before doing ear wash in animate foreign bodies. ❑ Removal by instruments (Hooks or crocodile forceps): If round or soft FB ,Gentle inserting of ear hook and rolling it outwards. If sharp or irregular FB , grasping and remove it with forceps.  General anaesthesia may be needed in impacted FB in: ❑ children or ❑ neurotic patients. A postauricular incision may rarely be needed in large impacted FB. Complications: ❑ usually results due to unskilled attempts of removal of FB: These are: ✔ Skin or tympanic membrane injury. ✔ Infection: Otitis externa. ✔ impaction. 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE: Etiology: ❑ Indirect trauma; due to sudden pressure changes: hand slaps (most common), barotraumas due to rapid pressure changes explosions. ❑ Direct trauma. Unskilled foreign body removal or ear wash ❖ for the correct syringing of the ear , the direction of the jet of water should be??? 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE (CONT.): Symptoms: ❑ History of trauma. ❑ Pain: usually severe but transient at the time of rupture. ❑ Bloody otorrhoea: mild and transient at the time of rupture. ❑ Hearing loss, tinnitus and autophony. ❑ Air may escape from the ear on nose blowing. 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE (CONT.): Signs: ❑ Blood in the external meatus. ❑ Tympanic membrane perforation with the following features: ❖ Always central in pars tensa. ❖ Usually small in size. ❖ Irregular in shape (with at least one acute angle). ❖ The edges are irregular sharp and hyperemic. ❖ Normal and healthy middle ear mucosa seen through the perforation. ❑ Conductive hearing loss by tuning fork tests. 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE (CONT.): Differential diagnosis: 1. pathological (due to chronic suppurative otitis media) and History Symptoms Examination (see table) 2. self-inflicted perforations (for medicolegal purposes). In self inflicted perforations, there is hesitation marks on the skin of the external auditory meatus perforations usually small and 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE (CONT.): 4. TRAUMATIC TYMPANIC MEMBRANE RUPTURE (CONT.): TREATMENT: ❑ Conservative treatment: usually successful in most cases and it comprises: Avoid ear contamination from water, ear drops &nose blowing. Prophylactic antibiotics. ❑ Surgical treatment: Myringoplasty is needed if the perforation fails to heal after 3 – 6 months. III. Trauma to the middle ear 1. OSSICULAR DISRUPTION. Etiology: ❑ Accidental head injury with or without temporal bone fracture. ❑ Iatrogenic trauma: ✔ Middle ear operations. ✔ Unskilled foreign body removal. Symptoms: ❑ Hearing loss and tinnitus with history of trauma. Signs: ❑ Intact or ruptured tympanic membrane. ❑ Tuning fork tests: Conductive hearing loss. 1. OSSICULAR DISRUPTION (CONT). Investigations: ❑ Pure tone audiometry: ❖ conductive hearing loss with air-bone gap >50 dB. ❑ Type Ad tympanogram if the drum membrane is intact. TREATMENT: ❑ Ossiculoplasty using bone, cartilage or 2. OTITIC BAROTRAUMA: It is physical trauma of the middle ear due to sudden and marked decrease of middle ear pressure below the atmospheric pressure in situations where there is no active opening of the Eustachian tube to equalize the middle ear pressure. It usually occurs: ❑ during airplane descent or ❑ during diving. Otitic barotraumas occurs if the patient fails to open the Eustachian tube during WHEN??. 2. OTITIC BAROTRAUMA (CONT.): During ascent to high altitude, the middle ear pressure becomes relatively positive and this can be easily corrected by passive outflow of air from the middle ear along the Eustachian tube. During descent, the middle ear pressure becomes relatively negative which can only be corrected by active opening of the Eustachian tube by swallowing or chewing to allow inflow of air through the Eustachian tube. 2. OTITIC BAROTRAUMA (CONT.): Failure to open the tube may caused by: ❑ Pressure difference more than 80 mm/Hg because of rapid descent or diving. ❑ The patient does not swallow (during sleep). ❑ The tube is obstructed as in: common cold, allergy, nasopharyngeal swellings. 2. OTITIC BAROTRAUMA (CONT.): Pathogenesis: ❑ Negative middle ear pressure will create a suction force on all walls of middle ear so mucosa becomes congested, edematous and tympanic membrane is retracted. the patient feels discomfort, hearing loss and tinnitus. Examination shows a retracted tympanic membrane. ❑ As the case progresses, middle ear effusion (either serous =effusion or bloody = haemotympanum) will result. pain, hearing loss and tinnitus increase and examination shows effusion or haemotympanum. ❑ Tympanic membrane rupture may occur if the descent is rapid and 2. OTITIC BAROTRAUMA (CONT.): Symptoms: ❑ Pain and discomfort (ear fullness). ❑ Hearing loss, autophony, and tinnitus. Signs: ❑ Signs of tympanic membrane retraction: Disturbed cone of light. Projecting lateral process of malleus. False shortening of handle of 2. OTITIC BAROTRAUMA (CONT.): ❑ Signs of effusion: Hair-line sign. Bubbles of air may appear with Valsalva maneuver. Decreased mobility of the tympanic membrane. ❑ If there is haemotympanum, the tympanic membrane is bluish in colour. ❑ There may be traumatic tympanic membrane rupture. ❑ Tuning fork tests show conductive hearing loss. 2. OTITIC BAROTRAUMA (CONT.): TREATMENT: ❑ Prophylactic: Avoid flying while having upper respiratory tract infection. Avoid sleeping during descent and Encourage opening of the Eustachian tube by: ✔ chewing gum, ✔ swallowing, and ✔ repeated auto-inflation of the middle ear by doing Valsalva’s maneuver 2. OTITIC BAROTRAUMA (CONT.): Curative treatment: ❑ Conservative treatment of effusion and tympanic membrane perforation: Vasoconstrictor nasal drops. Systemic antibiotics. Mucolytics with or without steroids. Avoid ear contamination in case of tympanic membrane rupture. ❑ Surgical treatment: After failure of conservative management. For effusion: Myringotomy without grommet’s tube insertion is done. For tympanic membrane perforation, myringoplasty is done after failure to heal spontaneously in 3-6 months. 3. FRACTURE BASE OF THE TEMPORAL BONE. SEVERE HEAD TRAUMA AS IN CAR ACCIDENT OR FALL FROM A HEIGHT 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). (A) LONGITUDINAL FRACTURE It is the common type (80%). Fracture line is in longitudinal axis of temporal bone. It involves the tympanic cavity, tympanic membrane and bony external canal. 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). (A) LONGITUDINAL FRACTURE Clinical Picture: ❑ Conductive deafness. ❑ Bleeding through ruptured D.M. and ❑ may be CSF otorrhoea. ❑ Facial N. paralysis is: uncommon and partial. delayed 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). (B) TRANSVERSE FRACTURE It is the less common type (20%). Fracture line is at right angle to the longitudinal axis of temporal bone. It involves: ❑ the labyrinth ❑ and or internal auditory meatus. 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). (B) TRANSVERSE FRACTURE Clinical Picture: ❑ Perceptive deafness (S.N.H.L.). ❑ Vertigo & Nystagmus. ❑ Haemotympanum which may contain also CSF. ❑ Facial N. paralysis is: more common and more severe. Immediate complete 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). Investigations: ❑ C.T. scan to assess the fracture line. ❑ Audiological tests to assess : Type of deafness. degree of deafness. Stapedial reflex. ❑ Tests for Facial nerve function. For localization, prognosis and management planning of facial nerve affection. 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). Neurosurgical treatment of the patient (for any associated coma or extradural haemorlrage,….) If CSF Otorrhea : ❑ Prophylactic antibiotics (that cross the blood - Prophylactic antibiotics. ❑ Semi sitting position and ❑ avoid straining. ❑ Sterile ear dressing. ❑ Neurosurgical repair by fascia late for some cases. 3. FRACTURE BASE OF THE TEMPORAL BONE (CONT.). Facial Nerve paralysis: ❑ Management of the facial nerve is done after stabilizing the general condition of the patient if incomplete and delayed usually recovers spontaneously but if severe and immediate ( indicating severe nerve injury ) ✔ do surgical exploration and ✔ nerve suture or graft. Treatment of Traumatic Rupture of D.M. & Ossicles (see b4). Vertigo: ❑ Vestibular sedatives Auditory rehabilitation: ❑ According to the type of hearing loss and residual cochlear 4. FOREIGN BODY IN MIDDLE EAR: In most of the cases the foreign body of the middle ear has arrived there by way of the canal ❑ if the FB in the external canal is impacted and tympanic membrane is ruptured. 5. FACIAL NERVE INJURY: Discussed in a separate lecture later. IV. Trauma to the inner ear 1. ACOUSTIC TRAUMA: Definition: ❑ It is a physiological trauma in which there is damage of the cochlear sense organ due to exposure to loud sounds According to etiology we have two types ❑ Very brief exposure to very loud sound e.g. gun fire leading to acute acoustic trauma ❑ Prolonged exposure to loud sound e.g. in some occupations as in spinning and weaving factories leading to chronic acoustic trauma. ACOUSTIC TRAUMA (CONT.): Clinical picture: ❑ SNHL and ❑ Tinnitus Treatment ❑ Prophylactic: By ear plugs or muffs Screening of hearing regularly in workers in noisy occupation ❑ Auditory rehabilitation 2. TRANSVERSE FRACTURE OF THE TEMPORAL BONE: Discussed before. 3. BAROTRAUMA OF THE INNER EAR: Rapid pressure fluctuation within the inner ear. With or without Rupture of round window membrane. Sudden sensorineural Hearing loss. Acute vertigo with loss of balance.