increased risk of inserting things in their ears Objects can cause trauma to the TM including possible perforation, and can disrupt the sensitive bony (medial) portion of the EAC, increasing the risk of infection Clinical Considerations Clinical Recognition Patients may present following a witnessed insertion of objects, the presence of otorrhea, decreased hearing, or pain In some cases, patients are asymptomatic and the foreign body is found incidentally during physical examination Objects may include stones, beads, foam, wax, paper, insects, or organic materials such as beans and popcorn kernels Ear foreign bodies are very common in children, especially those under years of age Triage The majority of children are well appearing, asymptomatic, or in mild/moderate pain Those with any bleeding from the ear or hearing loss require prompt evaluation Live insect foreign bodies are disconcerting and mineral oil or alcohol should be immediately instilled in the canal to euthanize them and stop further movement Initial Assessment The initial assessment should be focused on determining any history of object insertion, ear pain, or ear drainage as well as what type of object the foreign body might be This information is important for the removal plan Examination of the ear canal requires that the child remain very still to avoid advancing the foreign body or local trauma to the canal In addition to a handheld otoscope, a nasal speculum can be used to gently displace the tragus, and allow better visualization of the canal As with the otoscope, care must be taken when inserting the tines of the nasal speculum to prevent further insertion or impaction of the foreign body or injury to the canal skin Management Treatment focuses on safe removal of the foreign body (see Chapter 130 Procedures , Section on Ear Foreign Body Removal) In the emergency setting for the cooperative child, an ear curette can be used to scoop objects out or various otologic forceps (e.g., bayonet or alligator) can grasp objects Commercially available devices (e.g., Katz extractor) are available to help remove foreign bodies from the ear or nose When using these devices, a catheter is advanced behind the object, the balloon is inflated on the distal side of the object, and the catheter is withdrawn (with the balloon inflated) to extract the object Body temperature water can be used to irrigate and remove objects against the TM, provided the TM is intact Avoid irrigating organic objects (e.g., food, paper) as they can swell and become further lodged in the EAC Insects should be euthanized by instilling alcohol or mineral oil into the canal before attempting to remove them, again provided the TM is intact To reduce pain for these procedures a topical anesthetic can be applied in advance If the child is uncooperative with the procedure, there is risk of further damage to the EAC or TM, and procedural sedation in the ED could be considered Removal in the ED with sedation has the same safety profile as OR removal, potentially with lower cost Following successful removal, if there is excoriation or trauma to the EAC, topical combination antibiotic and steroid otic drops should be used to prevent otitis externa and to help decrease any inflammation Over-the-counter pain analgesia can be used for any minor discomfort If the foreign body cannot be successfully removed and there are no concerns for pain, bleeding, or infection, patients may be referred for removal by an otolaryngologist either in an ED that can provide procedural sedation or in a day surgery setting Ear Trauma Goals of Treatment The primary goal of treating ear trauma is to prevent cosmetic defects that could result from the injury and hearing loss, which is associated with lifelong disability In addition, optimal management of ear trauma reduces local infection risk, which, if left untreated, could result in cartilaginous infections and lead to worsened cosmetic appearance CLINICAL PEARLS AND PITFALLS Auricular hematomas should be identified and treated promptly Unrecognized traumatic perforation of the TM can lead to serious complications A thorough assessment of hearing including gross hearing, whisper test, and tuning fork assessment for both conductive and sensorineural hearing loss should be performed on all children with ear injuries EXTERNAL EAR Current Evidence Injury to the external ear can include laceration to the skin, soft tissue, or cartilage, as well as hematoma with risk of cartilage necrosis The cartilage of the ear is nourished and oxygenated by diffusion via the perichondrium With an auricular hematoma, bleeding avulses the perichondrial layer off the cartilage as the blood collects between them This separation of the perichondrium can lead to cartilage necrosis if not decompressed in a timely fashion In addition to blunt or sharp trauma, the external ears are also susceptible to thermal injuries including both burn and frostbite Clinical Considerations Clinical Recognition Injuries to the external ear can manifest as laceration, ecchymosis, or hematoma Thermal injury may present with bullous or peeling skin Most commonly, there is a reported history of trauma or symptoms of pain or bleeding that prompts the emergency clinician to recognize the injury However, unwitnessed or asymptomatic injuries may also be identified during examination Triage Any child with an external ear injury associated with serious trauma, active bleeding, new hearing loss, or neurologic symptoms should be evaluated emergently Most children will present with mild to moderate discomfort without associated symptoms and can be seen urgently Initial Assessment The initial assessment should focus on the mechanism and severity of the injury, examination for foreign body, and evaluation for other associated injuries The auricle should be inspected for any externally visible deformity/injury including lacerations or avulsions, with attention to any cartilage exposure, ecchymosis, or hematoma Note that isolated ecchymosis to the external ear canal without other signs of injury or with an inconsistent mechanism of injury should raise suspicion for nonaccidental trauma Diagnostic imaging is not routinely indicated for simple, isolated injuries Imaging should be considered to evaluate for associated injuries, including closed head injury or facial fractures, in the setting of concerning symptoms or findings (see Chapters 107 Facial Trauma and 113 Neurotrauma and Head Injury Clinical Pathway at https://www.chop.edu/clinicalpathway/head-trauma-acute-clinical-pathway ) Management Lacerations should be thoroughly irrigated and the wound closed primarily in a layered fashion If the injury involves cartilage, then these edges must be approximated and closed prior to repairing the cutaneous layers Hematomas should be drained and a pressure dressing applied to prevent accumulation Prompt drainage reduces the risk of permanent external ear deformity often referred to as “cauliflower ear.” In these cases, the wide incision should be made along or within the cartilaginous folds of the auricle to fully evacuate clot or fluid and to maximize cosmesis Some practitioners prefer to place a compression dressing utilizing dental rolls or petroleum gauze, while others prefer to place “quilting” sutures through-and-through the auricle with nonabsorbable suture There is demonstrated safety and effectiveness for surgical management Patients with traumatic ear injury who are discharged home should be encouraged to keep ear dressings in place to avoid infection, bleeding, or reaccumulation of hematomas The ears should be protected from further injury and exposure until fully healed They should be seen in to days by an appropriate medical provider to remove dressings and sutures For patients with auricular hematoma, assessment for any reaccumulation is also important Although data are limited, patients who have auricular hematomas drained may have a tenuous blood supply and, therefore, should receive a short course (commonly to 10 days) of prophylactic antibiotics Quinolones are often utilized as they cover routine skin flora (e.g., staphylococcus) as well as Pseudomonas aeruginosa , and have effective penetration into cartilage Although there are reported risks of arthropathy with quinolones, no clinical studies have demonstrated these findings in children Therefore, quinolones are felt to be the best choice in young children as well Amoxicillin with clavulanate is commonly recommended when there is hesitancy to use quinolones Even with empiric antibiotics, close monitoring for signs of chondritis including fever, erythema, or purulent drainage is important, which should prompt admission for intravenous antibiotic therapy Ears with cold thermal injury should be rapidly rewarmed and recooling should be avoided Hot thermal injuries should receive symptomatic care, avoiding excessive cooling or ice in direct contact of the ear skin MIDDLE EAR Current Evidence ... commonly, there is a reported history of trauma or symptoms of pain or bleeding that prompts the emergency clinician to recognize the injury However, unwitnessed or asymptomatic injuries may also