Pediatric emergency medicine trisk 817

Middle ear injury is commonly caused by barotrauma (e.g., pressure changes during air flight or deep-water pressure including swimming pools), forced air into the ear (e.g., slap injury), or from direct contact (e.g., wave or foreign body insertion) All three mechanisms can result in TM rupture and associated injury to middle ear structures Ossicles can be dislocated or fractured causing conductive hearing loss Injury to the oval or round window can lead to a perilymph fistula and significant vertigo Barotrauma is exacerbated in the child with eustachian tube dysfunction resulting in blood vessel engorgement and risk of bleeding or serous effusion into the middle ear Because the facial nerve traverses through the middle ear, injury resulting in facial paresis should prompt a careful evaluation for concurrent middle ear injuries Clinical Considerations Clinical Recognition Clinical recognition of injury occurs from identifying mechanisms consistent with middle ear injury including barotrauma, slap of air or water, or foreign object insertion Patients may be asymptomatic or complain of ear pain or drainage Other symptoms may include sudden onset vertigo, nystagmus, or hearing loss related to injury of the stapes or oval window Triage At triage, these patients are generally not ill-appearing, although differentiation of vertigo related to middle ear injury versus posterior fossa or neurologic etiology is important Initial Assessment History should focus on the mechanism of injury and any associated symptoms with a detailed review of neurologic symptoms The TM should be carefully examined for perforations Assess the function of the facial nerve given the association with middle ear injuries Hearing assessment should be performed on all children with concern for a middle ear injury Management Attempts at preventing airplane-associated barotrauma using saline drops for moisturization were found to have no effect For patients presenting with acute injury, imaging is often not indicated unless the mechanism is severe enough to warrant assessment for closed head injury Perforations with associated vertigo, nystagmus, tinnitus, or hearing loss require consultation with otolaryngology to determine appropriate management Perforations with active drainage should be treated with topical antibiotics for days to help minimize infection and wash away otorrhea or bleeding Patients with clear watery otorrhea, which raises the suspicion for CSF leak, or vertigo and other symptoms suggestive of perilymph fistula should be evaluated by an otolaryngologist prior to any administration of topical antibiotics Certain antibiotic drops will be painful due to particular ingredients or pH of the antibiotic preparation For example, Cipro HC is likely to cause burning pain, while Ciprodex is not Cortisporin should be avoided as neomycin, an aminoglycoside, can be ototoxic Middle ear bleeding or effusions can be treated with oral antibiotics to prevent infection and generally spontaneously resolve within to weeks It is critical that discharged patients with perforations follow up with an otolaryngologist for reexamination INNER EAR Current Evidence Concussive injuries, especially with associated temporal bone fracture, can disrupt the intracochlear membrane Children with certain bony anomalies of the inner ear, including semicircular canal dehiscence syndrome and enlarged vestibular aqueducts (EVAs), collectively known as third-window lesions, are susceptible to acute sensorineural hearing loss (SNHL) with even mild head trauma Noise-induced trauma can also damage the inner ear resulting in SNHL Acutely, loud blasts from explosions can cause sudden loss of hearing; this is typically less common in children given their pattern of exposure Clinical Considerations Clinical Recognition Inner ear injury is recognized by SNHL or the onset of vertigo in the context of an appropriate history Triage On presentation to triage, these children are not acutely ill-appearing but have a chief complaint of sudden hearing loss, dizziness, or tinnitus Initial Assessment The history should focus on the mechanism of injury, noise exposure, and the history/progression of the hearing loss Unless there are associated injuries, there is generally nothing visible on physical examination for inner ear injuries Comprehensive audiologic testing is paramount and should be performed as soon as possible to document the presence, nature, and extent of hearing impairment Tuning fork tests (i.e., Weber and Rinne) should be performed to help determine the likely etiology for any hearing loss To evaluate for third-window lesions, a high-resolution CT of the temporal bones is required Otolaryngology should be consulted in patients with suspected inner ear injury to determine the need for further evaluation and management Antibiotic treatment or admission is not routinely indicated However, systemic corticosteroids (1 mg/kg/day of prednisone or an equivalent) should be administered for new onset sudden SNHL Steroids are most effective if initiated within 24 to 48 hours of the loss OTHER INJURIES ASSOCIATED WITH EAR TRAUMA Temporal Bone Fracture Approximately 80% of temporal bone fractures are in the longitudinal orientation and 20% are transverse The location may help predict associated findings including facial nerve injury and hearing loss Longitudinal fractures are usually extralabyrinthine and may disrupt the bony annulus of the TM causing hemotympanum and ossicular or TM disruption Facial nerve injury is rare with longitudinal fractures Transverse fractures can disrupt the otic capsule, internal auditory canal, and the seventh and eighth cranial nerves Approximately half of transverse fractures have facial nerve involvement If the fracture involves the otic capsule, SNHL is common Otolaryngology should be consulted for patients with facial nerve injury for evaluation, management, and possible emergent decompression or repair if the nerve is severed (i.e., neurorrhaphy) CSF Otorrhea Longitudinal fractures that rupture the TM can lead to CSF otorrhea Transverse fractures have a higher incidence of CSF leak, but are less likely to have otorrhea due to an intact TM Clear fluid in the canal should be evaluated to determine if it is CSF Water, tears, or home therapies can also be present A halo of clear fluid around any red blood cells when placed on filter paper is concerning for CSF (i.e., halo test) Glucose testing can also be performed However, beta-2transferrin testing is considered the most specific test to confirm CSF otorrhea Avoid manipulation or instrumentation when CSF otorrhea is thought to be present, to reduce risk of meningitis through the introduction of bacteria Patients with CSF otorrhea are often treated with bed rest with the head of the bed elevated Otolaryngology and neurosurgery should be consulted Prophylactic antibiotics are controversial TRAUMA TO THE NOSE AND SINUSES Nasal Foreign Body Goals of Treatment The goal of treatment is to identify a nasal foreign body, to allow prompt removal Safe removal of the foreign body reduces the risk of acute aspiration, subacute local infection, sinusitis, and cartilaginous injury CLINICAL PEARLS AND PITFALLS Unilateral malodorous nasal discharge should raise suspicion for a nasal foreign body Care must be taken to avoid pushing or irrigating the object during examination or removal attempts, as migration to the nasopharynx puts the child at risk for aspiration Pretreatment with vasoconstrictor as well as use of a nasal speculum can improve visualization and facilitate removal A known or suspected disc battery should be removed immediately to avoid caustic injury Current Evidence Foreign bodies can obstruct the nares If the object has been present for an extended duration, granulation tissue can form around the object Either the tissue or the object itself can block the ostia and increase the risk of infection Clinical Considerations Clinical Recognition Witnessed insertion or foul unilateral discharge is key to diagnosing a nasal foreign body Triage Children generally present to triage well appearing with a history consistent with foreign body Rarely, associated injury may result in epistaxis that should be addressed urgently Nasal foreign bodies can migrate posteriorly, changing a