Traumatic Ear Canal Injury

Traumatic ear canal injury is damage to the skin, cartilage or bone of the external ear canal, with or without injury to the eardrum, from mechanical, thermal, chemical, blast or barotraumatic causes. Most small lacerations and traumatic perforations heal spontaneously within 2 to 4 weeks.

• Common causes: cotton buds, hairpins and fingernails; attempts to remove foreign bodies; faulty ear irrigation; a slap to the ear; sport; road traffic accidents or falls causing temporal bone fracture; mandibular condyle fracture displaced into the canal; burns (welding spatter, hot liquids); chemical injury including button batteries; insects; hearing aid mould trauma; diving barotrauma.
• Consequences: laceration and bleeding, haematoma, eardrum perforation, ossicular disruption, secondary otitis externa, canal stenosis, cholesteatoma from implanted skin, hearing loss, facial nerve palsy, perilymph fistula, cerebrospinal fluid leak.

• Sudden ear pain, bleeding or blood stained discharge, hearing loss, tinnitus, fullness, vertigo, often after a specific incident.
• Otoscopy or microscopy: blood clot, wall laceration, swelling, foreign body, a sharp edged perforation with blood on its margins, haemotympanum, burn change, battery.
• Red flags: canal bleeding with head injury or step deformity of the canal wall (temporal bone fracture); clear fluid with a halo sign (CSF leak); facial weakness; profound or sensorineural hearing loss; severe vertigo with nystagmus; Battle sign; a button battery in the canal (emergency); chemical burn; large perforation; auricular haematoma; blast injury; spreading cellulitis; diabetes or immunosuppression.

• Careful otoscopic or microscopic examination, gently suctioning clots under direct vision. Do not irrigate.
• Tuning fork tests and pure tone audiometry (conductive loss suggests perforation or ossicular injury; sensorineural loss suggests inner ear injury). Repeat at 4 to 6 weeks.
• Facial nerve and cranial nerve examination; Dix-Hallpike or fistula test if vertigo.
• High resolution CT of the temporal bone for suspected fracture, ossicular disruption, foreign body or intracranial extension; CT head if head injury.
• Swab for culture if discharge persists.
• Differentials: otitis externa, acute otitis media with perforation, cholesteatoma, tumour, foreign body, impacted wax with excoriation.

• Keep the ear dry (no swimming; use a petroleum jelly coated cotton wool plug for showers). Avoid syringing, cotton buds and forceful nose blowing.
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g per day), ibuprofen 400 mg every 8 hours with food.
• Minor laceration or abrasion without perforation: gentle microsuction cleaning and ciprofloxacin 0.3 percent with dexamethasone 0.1 percent drops, 3 to 4 drops twice daily for 5 to 7 days. Review at 1 week.
• Traumatic perforation: avoid ototoxic drops (neomycin, gentamicin, polymyxin B, framycetin). If the ear is contaminated, use ciprofloxacin 0.3 percent drops 3 to 4 drops twice daily for 5 to 7 days. Keep dry. Audiogram at 4 to 6 weeks. Refer to ENT if no closure by 3 months, hearing loss persists above 30 dB, or the ossicles are damaged (tympanoplasty or ossiculoplasty). Large perforations with inverted edges need early ENT review.
• Foreign body: removal by ENT or a trained clinician with microsuction, hooks or forceps. For a live insect, kill it first with mineral oil or lidocaine 2 percent drops (not with perforation). A button battery needs emergency removal.
• Burns: cool with running water, dress, apply topical antibiotic, ENT review.
• Canal swelling or clot: insert an ear wick and use ciprofloxacin steroid drops to keep the canal open.
• Auricular haematoma: drain within 24 hours and apply a compression bolster to prevent cauliflower ear.
• Cellulitis or contaminated wounds: co-amoxiclav 625 mg orally three times daily for 5 to 7 days (add ciprofloxacin 500 mg twice daily if Pseudomonas is a concern). Update tetanus immunisation for dirty wounds.
• Temporal bone fracture, CSF leak, facial palsy or sensorineural loss: admit under ENT and neurosurgery. Prednisolone 1 mg/kg for 7 to 10 days is used for sudden sensorineural loss or facial palsy (specialist decision).
• Follow up at 1 to 2 weeks and at 4 to 6 weeks with audiometry. Counsel that nothing should be placed in the ear.