Diagnostics and Therapeutics: Ear Emergencies in the Department
/Chief complaints involving the ear are a common occurrence in Emergency Departments across the US and include presenting symptoms such as ear pain or fullness, hearing loss, redness, trauma, vertigo, and foreign bodies. A retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011 identified 8.6 million visits resulting in otologic diagnoses, encompassing about 1.01% of all adult visits and 6.79% of pediatric visits (1). In this post we will discuss a few of the most common ear complaints and the approach to their management.
AURICULAR HEMATOMAS
Diagnosis
Auricular hematomas are collections of blood in the potential space between the perichondrium and the underlying cartilage of the ear. This is usually caused by blunt trauma and is most commonly seen in wrestlers, mixed martial artists, or boxers. A thorough trauma history and physical exam should be performed including evaluation for bony fracture in the surrounding structures of the face.
A) on LEFT: Auricular hematoma with overlying tattoos. Courtesy of wiki commons under CC Attribution 3.0 germany File:Hematoma ear.jpg - Wikimedia Commons. B) on right: hand drawn images of layers of ear demonstrating auricular hematoma
The epidemiology and incidence of ED presentation for auricular hematomas has not been well-studied because it is a relatively uncommon condition. However, it is an important diagnosis to recognize and promptly treat because of long term complications when not managed properly. Specifically, pressure from blood accumulation in this space can lead to vascular compromise, necrosis of the cartilage, and ultimately chronic deformities such as “cauliflower ear” (2).
Alternate diagnoses should be considered if warmth, diffuse tenderness, swelling of the external auditory canal, drainage, or hearing loss is present on exam. Additionally, necrotic cartilage from auricular hematomas can increase the risk of secondary infections such as cellulitis and perichondritis. Therefore, both of these should be important considerations as well when evaluating swollen ears in the emergency department.
Treatment - How to Drain
Auricular hematomas are treated with evacuation and compression to prevent re-accumulation of hematoma. Complications of auricular hematoma drainage include pain, paresthesia, bleeding, infection, poor cosmetic outcome, scar formation, and re-accumulation of hematoma after the procedure. A hematoma that has been present for more than 7 days should be referred to ENT for drainage as the patient will likely necessitate debridement of neocartilage that may have begun forming (3).
Anesthesia can be achieved with auricular ring blocks and/or via direct infiltration of lidocaine into the hematoma. Lidocaine with epinephrine can be used for regional blocks but should be avoided with direct infiltration into the ear tissue as the epinephrine causes vasoconstriction and may compromise perfusion when used in small anatomic areas (4).
Hematomas can be drained either by needle aspiration or with a formal incision and drainage (I&D). Simple needle aspiration with an 18-gauge needle can be considered for acute hematomas present <48 hours which are <2 cm in size, but this strategy leaves an increased risk of re-accumulation if performed on larger or subacute injuries (2,6). Incision and drainage tends to be the most common procedure for evacuation and appears to have the lowest likelihood for re-accumulation. Other strategies have also been discussed in the literature including leaving an indwelling 18-gauge IV catheter in place for drainage, however, this has not been well-studied and requires closer follow-up.
Hematoma evacuation with I&D can be assisted with the use of curved hemostats and the cavity should then be irrigated with sterile saline. It is recommended to hold manual pressure for 3-5 minutes after evacuation.
See video under “Follow-up” below for demonstration of I&D technique for auricular hematoma as well as creation of compression bolster dressings and placement of these.
You can also refer to Taming the SRU’s Mastering Minor Care post by Dr. Ijaz from 2020 for the review of auricular ring blocks, hematoma evacuation, and techniques to prevent re-accumulation. Click here to link to this post.
Treatment - Compression Dressing
Regardless of how drainage is achieved, a compression dressing should be applied to prevent re-accumulation of blood. Newer strategies have been proposed such as using molded silicone splint material, but these are not yet widely accepted (5). A sewn-in bolster dressing with dental rolls is preferred both by providers and patients as simple compression dressings around the ear require the patient to leave a roll of gauze bandage wrapped around their head for a week and often have lower compliance as a result. For a sewn-in bolster, use of 4-0 non-absorbable sutures is recommended, with mattress sutures closing the drainage incision but also going through dental rolls on either side of the pinna for compression (6). The incision site should be coated with antibiotic ointment and the anterior dental roll can be wrapped with non-adherent petrolatum gauze prior to being secured.
Follow-up
Standard wound care education and return precautions should be given. Patients should keep a sewn-in bolster dressing clean and dry (recommend using a shower cap) and NSAIDs should be avoided due to the theoretical increased risk of re-bleeding. Physical activity should be limited and contact sports avoided for about 2 weeks (7).
Follow-up with ENT should occur in about 1 week for removal of bolsters and sutures. If using only a simple pressure dressing, then daily wound checks and reapplication of compression dressing should occur for 72 hours.
Although evidence is overall lacking, a 7- to 10-day course of oral antibiotics is suggested to prevent infection in this area with tenuous blood supply. An oral anti-pseudomonal such as levofloxacin is first-line, and amoxicillin-clavulanic acid may be used in younger children to cover skin flora as fluoroquinolones are still not recommended in children <18 years of age (2,8).
Video example of I&D and compression dressing placement
perichondritis and other infections
The ear has several layers, as shown in the diagram in part one of this post. One of which is the perichondrium, which is a dense connective tissue that covers the cartilage of the ear. This area can present with infections such as perichondritis, which often occur after penetrating trauma such as after a high chondral ear piercing. It can also be caused by an auricular hematoma that is left untreated and becomes infected, or as a direct extension of an otitis externa infection (9).
Patients usually present with tender, erythematous, diffusely indurated pinna with a shiny overlying surface. Typically these can be differentiated from otitis externa by the sparing of the inferior lobule and external auditory canal, although both diagnoses may coexist. Cellulitis and erysipelas are more superficial skin infections that will present with erythema and are differentiated from perichondritis by an absence of induration and lobular involvement. While sometimes indistinguishable clinically, the term “chondritis” is used when perichondritis progresses to involve the cartilage itself, with cartilage cavitation or abscess formation (10).
Pseudomonas is the most common bacteria involved in perichondritis, so all patients with this suspected diagnosis should be treated with both an oral and topical quinolone antibiotic and removal of the source (earring, drainage of hematoma/ abscess) if present. Presence of an abscess or systemic symptoms of infection should warrant careful consideration of admission for IV antibiotics (11). Similar to auricular hematomas, this infection can lead to cosmetic deformities due to disruption of the normal histologic structure of the cartilaginous framework of the ear (12).
When any of the above are suspected, a full HEENT exam should be performed. Specifically, ED providers should evaluate for mastoid tenderness, hearing loss, and middle ear effusion / infection. Otitis externa should also be higher on the differential with presence of otorrhea / canal involvement. If concerned about significant trauma, foreign body, or spreading infection such as malignant otitis externa or mastoiditis, the middle ear and mastoid may be better investigated with a CT scan.
Bilateral or recurrent auricular swelling should prompt referral for rheumatologic evaluation for uncommon conditions such as Kimura’s or Winkler's disease (13).
Foreign Bodies
Foreign bodies (FB) in the external auditory canal (EAC) are a common discovery for the emergency physician to make when a patient is complaining of ear pain and fullness or sometimes even hearing loss. Often children may not present until purulent drainage is noticed and fulminant otitis externa has developed. In adults, the most common FBs are insects, while in pediatric patients foreign bodies can be anything from food items (peas, rice), organic matter (dirt, leaves), and inorganic objects (small batteries, beads, other toy pieces).
Removal of foreign bodies in the ear should always be attempted, as FBs can serve as a nidus for infection or cause trauma to the tympanic membrane (TM). It is important to realize that the osseous portion of the external auditory canal is extremely sensitive because the thin skin is tightly adherent to the underlying periosteum, thus you may think you have touched the TM when it likely was just the osseous portion of the canal.
ED providers should keep several FB removal techniques in their clinical toolbox, as the best method is mostly dependent on the characteristics of the foreign body. For example, alligator forceps are great for irregular-shaped objects, but can cause round, smooth objects to become lodged deeper in the EAC.
Foreign body removal steps
Assess hearing before and after the procedure and document any suspected damage/injury prior to removal attempts so that these will not later be attributed to the procedure (6).
Recruit an assistant to help with patient positioning and holding the ear in the correct position with the pinna upward and outward to straighten the canal. The assistant can also hand tools to the physician throughout the procedure.
A debate in literature remains regarding use of topical lidocaine versus mineral oil for insect drowning and extraction. Topical 2 or 4% lidocaine may be used for anesthesia for patients with significant discomfort and has the added benefit of drowning an insect prior to removal which is recommended (8). Mineral oil is also useful for insects however does not have the added effect of topical analgesia for patients that have significant discomfort.
Irrigation is helpful for small, loose objects such as sand but not for objects that may swell when wet (such as seeds). Irrigation is contraindicated if TM rupture is suspected or if the FB is a button battery (14).
Alligator forceps are useful for irregular, graspable objects like paper and fragments of toys.
Round, smooth objects tend to be some of the more difficult objects to remove and some tools to consider having handy include suction-tipped catheters, right-angle hooks, curettes, and balloon-tipped extraction devices (14).
When to Consult for Foreign Bodies
ENT, if available, should be called for assistance after only a few failed attempts because repetitive trauma to the canal can lead to swelling and patient discomfort and may decrease cooperativity with future attempts. A consult is also recommended when a foreign body has a concomitant infection or when it is associated with TM rupture. Consider a consult for objects that tend to be more complicated to remove such as significantly impacted objects, sharp objects, and button batteries (6). Indications for otolaryngology referral after ED follow-up are failed object removal or injury to the TM or EAC. If there is an injury to the TM or the EAC during foreign body removal, follow-up with ENT in 3-5 days is recommended in addition to prescribing the patient ciprofloxacin/corticosteroid suspension drops for infection in the interim (14).
references
1. Kozin ED, Sethi RK, Remenschneider AK, et al. Epidemiology of otologic diagnoses in United States emergency departments. Laryngoscope. 2015;125(8):1926-1933. doi:10.1002/lary.25197
2. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear. Facial Plast Surg. 2010 Dec;26(6):451-5.
3. Dinces EA. How to Drain an Auricular Hematoma. Merck Manuals Professional Edition. June 2023. Accessed November 9, 2023.
4. DeBoard RH, Rondeau DF, Kang CS, Sabbaj A, McManus JG. Principles of basic wound evaluation and management in the emergency department. Emerg Med Clin North Am. 2007 Feb. 25(1):23-39.
5. Choung YH, Park K, Choung PH, Oh JH. Simple compressive method for treatment of auricular haematoma using dental silicone material. J Laryngol Otol. 2005 Jan;119(1):27-31. doi: 10.1258/0022215053222932. PMID: 15807959.
6. Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Seventh edition. Elsevier; 2018.
7. Krogmann RJ et al. Auricular Hematoma. [Updated 2018 Dec 16]. Stat Pearls.
8. Noel GJ, Bradley JS, Kauffman RE, Duffy CM, Gerbino PG, Arguedas A, Bagchi P, Balis DA, Blumer JL. Pediatr Infect Dis J. 2007 Oct;26(10):879-91.
9. Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondritis of the auricle and its management. J Laryngol Otol. 2007 Jun;121(6):530-4.
10. Pattanaik S. Effective, simple treatment for perichondritis and pinna haematoma. J Laryngol Otol. 2009;123(11):1246–9.
11. Khan N, Cunning N. Pinna Perichondritis. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
12. Cummings CW Flint PW. Cummings Otolaryngology--Head & Neck Surgery. Seventh ed. Philadelphia PA: Elsevier/Saunders; 2021.
13. Toshiki Ito, Recurrent auricular inflammation caused by Kimura’s disease: reminiscent of the early phase of relapsing polychondritis?, Oxford Medical Case Reports, Volume 2019, Issue 9, September 2019, omz091.
14. Dinces EA. How to Remove a Foreign Body from the External Ear. Merck Manuals Professional Edition. June 2023. Accessed November 7, 2023.
Photos:
https://upload.wikimedia.org/wikipedia/commons/c/c2/Hematoma_ear.jpg
https://commons.wikimedia.org/wiki/File:Erckscauliflowerear.jpg
https://commons.wikimedia.org/wiki/File:Perichondritis2020.jpg
post by nicole lewis, md
Dr. Lewis is a PGY-1 in Emergency Medicine at the University of Cincinnati.
Editing by Anita Goel, MD
Dr Goel is Assistant Professor in Emergency Medicine at the University of Cincinnati and an assistant editor of TamingtheSRU.com
