Rosen & Barkin's 5-Minute Emergency Medicine Consult (501 page)

• Severe ear pain
  
• Bleeding
  
• Signs of auricular deformity:
  
  • Edema
    
  • Hematoma:
    
    • Bluish, fluctuant, or doughy swelling of auricle
      
  • Laceration
    
  • Amputation
    
  • Loss of contour of the pinna
    
• Signs of middle ear trauma:
  
  • Decreased hearing:
    
    • Partial loss suggests TM rupture
      
    • Complete loss suggests injuries to ossicles or inner ear
      
  • Tinnitus
    
  • Middle ear effusion or canal drainage
    
  • Peripheral facial nerve paralysis
    
  • Vestibular symptoms, i.e., nystagmus or vertigo:
    
    • May also result from inner ear injury
      
• Signs of basilar skull fracture:
  
  • Hemotympanum or serous effusion
    
  • Retroauricular hematoma (battle sign)
    
  • CSF otorrhea or rhinorrhea
    
  • Peripheral facial nerve paralysis
    

• Mechanism
  
• Associated injuries
  
• Past otologic history
  
• Medications and allergies
  

• Head
  
• Cranial nerves
  
• Vascular structures
  
• Pinna
  
• External ear canal
  
• TM
  
• Hearing
  
• Consider the Weber and the Rinne test to evaluate for conductive hearing loss due to TM rupture or perforation:
  
  • Rinne test: Place a struck tuning fork to mastoid tip, hold until patient no longer hears ringing, then place fork near external auditory opening:
    
    • Normal: Patient still hears ringing; air conduction > bone conduction
      
    • Abnormal: No sound heard; air conduction < bone conduction; implies a conductive hearing loss
      
  • Weber test: Place a struck tuning fork to center of forehead:
    
    • Normal: Equal sound perception in both ears
      
    • Abnormal due to neurosensory loss: Patient will have decreased sound perception in the impaired ear
      
    • Abnormal due to conductive loss: Increased sound perception in the impaired ear
      
• Be sure to evaluate for concomitant injuries
  

Wound culture if signs of infection

• Consider head and/or facial CT to evaluate for intracranial injury or bone fracture
  
• Consider CT temporal bone without contrast if evidence of serious middle ear injury
  

• Infection
  
• Hemangioma
  
• Foreign body in ear
  

TREATMENT

If auricle is amputated, wrap in moist gauze and place in plastic bag

• Check ABCs; full trauma evaluation; resuscitation as appropriate
  
• Sterile dressing to injured site
  

• All injury types:
  
  • Anesthesia:
    
    • Local anesthesia via nerve block to auriculotemporal branch of mandibular nerve, lesser occipital nerve, greater auricular nerve, and auricular branch of vagus nerve; use 1% lidocaine or 0.25% marcaine
      
    • Alternative: Inject ring of anesthetic around base of pinna
      
• Tetanus prophylaxis if necessary
  
• Specific injury types:
  
  • Auricular hematoma: Drainage imperative to reapproximate perichondrium to cartilage to prevent cartilage necrosis, ideally within 72 hr; however, no clearly defined best treatment
    
    • Antistaphylococcal antibiotics for 7–10 days
      
    • Aspiration: Preferred alternative if clot not yet formed; use 18G–20G needle for aspiration milk hematoma until totally evacuated; apply pressure dressing
      
    • Incision and drainage: More effective with larger and/or clotted hematomas; incise along curvature of pinna with no. 15 scalpel, evacuate, and irrigate; apply pressure dressing
      
    • Vaseline gauze pressure dressing: Place to fill crevices of pinna; place over and behind pinna; wrap soft gauze firmly around head
      
    • Alternative pressure dressing: Suture dental rolls into place over incised area
      
    • If patient has 2nd presentation due to reaccumulation, hematoma should be reaspirated and a wick placed for drainage
      
• Laceration:
  
  • Prophylactic antibiotics are controversial but for human and animal bites treat with amoxicillin–clavulanate
    
  • Clean and debride wound, anesthetize as necessary
    
  • Superficial abrasions: Clean, dress with antibiotic ointment
    
  • Simple lacerations: 5 or 6 monofilament nylon or polypropylene suture, then pressure dressing; may use absorbable suture to avoid having to bend ear for suture removal
    
  • Exposed auricular cartilage: Carefully debride jagged edges; completely cover cartilage to prevent perichondritis; can remove small amount of cartilage to allow skin coverage; approximate cartilage 1st with absorbable sutures at major landmarks; include anterior and posterior perichondrium in stitch
    
  • Avulsions:
    
    • <2 cm total avulsions may be used as graft and survive
      
    • >2 cm: Consult or urgently refer to otolaryngologist or plastic surgeon
      

• Amoxicillin–clavulanate: Adults: 875/125 mg PO BID (peds: 40 mg/kg/d PO BID)
  
• Dicloxacillin: 250–500 mg PO QID (peds: 30–50 mg/kg/d PO div. q6h)
  

FOLLOW-UP

• Concomitant serious traumatic injuries
  
• Need for IV antibiotics
  
• Immunosuppressed persons with serious infections, perichondritis, or chondritis
  

• Able to tolerate oral antibiotics
  
• Able to arrange close follow-up
  

• Follow up wound suture repair in 5 days
  
• Follow up hematomas in 24 hr to evaluate for reaccumulation
  

• Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma.
  Laryngoscope
  . 2005;115:1251–1255.
  
• Jones SE, Mahendran S. Interventions for acute auricular haematoma.
  Cochrane Database Syst Rev
  . 2004;(2):CD004166.
  
• McKay MP, Mayersak RJ. Facial trauma. In: Marx J, Hockberger R, Walls R, eds.
  Rosen’s Emergency Medicine
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Riviello RJ, Brown NA. Otolaryngologic procedures. In: Rogers JR, Hedges J, eds.
  Clinical Procedures in Emergency Medicine
  . 5th ed. Philadelphia, PA: WB Saunders; 2009.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Barotrauma
  
• Tympanic Membrane Perforation
  

CODES

• 380.00 Perichondritis of pinna, unspecified
  
• 920 Contusion of face, scalp, and neck except eye(s)
  
• 959.09 Injury of face and neck
  

BASICS

• Ovarian cysts:
  
  • Generally asymptomatic until complicated by hemorrhage, torsion, rupture, or infection
    
  • Follicular cysts:
    
    • Most common
      
    • Occur from fetal life to menopause
      
    • Unilocular; diameter 3–8 cm
      
    • Thin wall predisposes to rupture, which usually causes minimal or no bleeding
      
    • Rupture during ovulation at midcycle is known as mittelschmerz
      
  • Corpus luteal cysts:
    
    • Most significant
      
    • Diameter 3 cm, but usually <10 cm
      
    • Rapid bleeding from intracystic hemorrhage causes rupture
      
    • Rupture is most common just before menses begins
      
    • Can cause severe intraperitoneal bleeding
      
    • Gradual bleeding into cyst or ovary distends capsule and may cause pain without rupture
      
• Adnexal torsion:
  
  • 5th most prevalent surgical gynecologic emergency
    
  • Twisting of vascular pedicle of ovary, fallopian tube, or paratubal cyst
    
  • Causes adnexal ischemia leading to necrosis
    
  • Occlusion of lymphatics and venous drainage lead to rapid enlargement of adnexa
    
  • Greatest risk with cysts 8–12 cm