Pediatric emergency medicine trisk 3265 3265

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