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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