Traumatic Ear Canal Laceration

Traumatic ear canal laceration is a tear of the skin of the external auditory canal from direct trauma, most often from cotton buds and other objects pushed into the ear, and it can be associated with injury to the tympanic membrane or ossicles.

• Causes: cotton buds, pens, hairpins, fingernails, attempts to remove wax or foreign bodies, blunt head trauma with temporal bone fracture, firearm injuries, and explosions.
• The skin is thin and tightly bound to bone in the inner canal, so it tears easily.
• Blunt trauma to the jaw can fracture the anterior canal wall via the temporomandibular joint.
• Most minor lacerations heal in 1 to 2 weeks.

Pain and bleeding are the usual symptoms.

• Sudden ear pain after an insertion injury, with blood-stained discharge or blood in the canal.
• Reduced hearing, tinnitus, and fullness.
• Otoscopy: laceration, clot, canal swelling, bruising or exposed bone.
• Tympanic membrane perforation, haemotympanum, or ossicular disruption.
• Vertigo, sensorineural hearing loss, facial weakness and clear fluid discharge point to inner ear injury, facial nerve injury or cerebrospinal fluid otorrhoea (temporal bone fracture).
• Differential diagnosis: otitis externa, foreign body, perforation, temporal bone fracture, barotrauma, canal furuncle and cholesteatoma.
• Complications: infection (otitis externa, perichondritis), canal stenosis or atresia, tympanic membrane perforation, hearing loss, ossicular dislocation, facial nerve injury, cerebrospinal fluid leak and cholesteatoma.

Diagnosis is by otoscopy or microscopy.

• Gentle suction of clots under the microscope; avoid irrigation.
• Examine the drum, facial nerve function, nystagmus and Weber and Rinne tests.
• Pure tone audiometry for hearing loss (baseline and follow-up).
• High-resolution computed tomography of the temporal bone for head trauma, facial paralysis, vertigo, sensorineural loss, cerebrospinal fluid leak or bone exposure.
• Glucose or beta-2 transferrin on clear fluid if cerebrospinal fluid leak suspected.

Most lacerations heal with dry ear care.

• Supportive: keep the ear dry (cover with cotton wool and petroleum jelly when bathing), avoid insertion of any object, analgesia, head elevation, and no nose-blowing if a skull base fracture is suspected.
• Pharmacological: topical antibiotic drops (ciprofloxacin 0.3 percent, 3 to 5 drops twice daily for 5 to 7 days; this is safe if the drum is perforated). Avoid aminoglycoside drops with perforation. Analgesia: paracetamol 1 g every 6 hours (children 15 mg/kg).
• Systemic antibiotics for contaminated wounds, cellulitis or exposed cartilage or bone: amoxicillin-clavulanate 625 mg three times daily (children 25 mg/kg twice daily) for 5 to 7 days. Tetanus prophylaxis as indicated.
• Procedures: microscopic toilet, repositioning of skin flaps, and packing of the canal with an antibiotic-impregnated wick or stent for large lacerations to prevent stenosis. Surgical repair for exposed bone, complete circumferential injury, or canal fracture. Tympanoplasty for non-healing perforation. Facial nerve exploration for immediate complete palsy after trauma.
• Special groups: children need sedation or general anaesthesia for examination and treatment. Suspected assault requires documentation.
• Red flags: facial weakness, vertigo, sensorineural hearing loss, clear fluid discharge, exposed bone, bleeding that does not stop, and head trauma.
• Follow-up: review at 1 to 2 weeks, repeat audiometry at 4 to 6 weeks. Perforation not healed by 3 months needs ENT review. Watch for canal stenosis.