Differential Diagnoses for 8-Year-Old Male Struck on Ear with Soccer Ball
The primary differentials to consider are auricular hematoma, external ear contusion, concussion, tympanic membrane injury, and less commonly, temporal bone fracture or intracranial injury.
Immediate Assessment Priorities
Concussion Evaluation (Most Critical)
- Any child struck in the head region with a soccer ball must be immediately evaluated for concussion, even if the impact was primarily to the ear 1
- Look for obvious signs including fluctuating consciousness, balance problems, memory issues, and concentration difficulties 1
- Ask about self-reported symptoms: headache, ringing in ears (tinnitus), nausea, dizziness, or blurred vision 1
- If ANY concussion symptoms are present, the child must be removed from play immediately and not allowed to return the same day 1, 2
- Monitor vital signs and level of consciousness every 5 minutes if concussion is suspected 1
External Ear Injury Assessment
- Examine for auricular hematoma (collection of blood between cartilage and perichondrium), which appears as a fluctuant, purple swelling that obscures normal ear contours 3, 4
- Check for lacerations, abrasions, or contusions of the external ear 4, 5
- Assess for deformity or swelling that might indicate underlying cartilage injury 3, 4
Middle/Inner Ear Evaluation
- Examine tympanic membrane for perforation, hemotympanum, or signs of barotrauma 3
- Test hearing acuity (even informally by asking if hearing is normal) 3
- Assess for vertigo or balance problems, which could indicate inner ear injury or concussion 1, 3
Key Differential Diagnoses
1. Concussion (Highest Priority)
- Soccer balls striking the head/ear region can cause concussion even without direct cranial impact 6, 7
- Symptoms may be delayed, requiring monitoring for several days 1
- Children typically have longer recovery times (7-10 days or more) than adults 1, 2
2. Auricular Hematoma
- Results from shearing forces causing separation of perichondrium from cartilage 4
- Requires urgent drainage within 24-48 hours to prevent "cauliflower ear" deformity and chondritis 3, 4
- Treated with evacuation and pressure dressing using sterile technique 4
3. External Ear Contusion/Abrasion
- Most common minor injury pattern 3, 5
- Can be cleaned with good quality water and monitored for infection 5
4. Tympanic Membrane Injury
- Less common but possible with direct ear trauma 3
- Presents with hearing loss, ear pain, or bloody discharge 3
5. Temporal Bone Fracture (Rare but Serious)
- Consider if severe mechanism, persistent altered consciousness, or focal neurological deficits 1
- Requires CT imaging for diagnosis 1
Management Algorithm
If Concussion Suspected:
- Complete physical and cognitive rest for first 24-48 hours 2
- No return to play until completely asymptomatic at rest and with exertion 1, 2, 8
- Follow stepwise return-to-play protocol taking minimum 5 days, with each stage lasting at least 24 hours 2, 8
- Refer to concussion specialist if symptoms persist beyond 10-14 days 2
If Auricular Hematoma Present:
- Immediate drainage and pressure dressing application to prevent chondritis 4
- Follow-up within 24 hours to check for reaccumulation 4
If Simple Contusion/Abrasion:
- Clean wound thoroughly, remove foreign material 5
- Monitor for infection 5
- Ensure tetanus prophylaxis is current 5
Critical Pitfalls to Avoid
- Never dismiss head/ear trauma as minor without proper concussion screening 1
- Never allow same-day return to play after any head impact with symptoms 1, 2
- Never delay auricular hematoma drainage, as this leads to permanent deformity 3, 4
- Do not assume absence of loss of consciousness rules out concussion 1
- Monitor for delayed symptoms over subsequent 48-72 hours 1