What is the workup for ear pain after a fall onto a tub?

Workup for Ear Pain After Fall onto Tub

Perform a focused otoscopic examination to differentiate primary otalgia (ear pathology) from secondary otalgia (referred pain), as the ear exam will be abnormal in primary causes and normal in secondary causes. 1, 2

Initial Assessment

History Taking

• Mechanism of injury: Determine if direct trauma occurred to the ear itself, periauricular area, or head/jaw region 1
• Timing and character of pain: Immediate onset suggests traumatic injury; delayed onset may indicate developing infection or inflammation 2
• Associated symptoms to assess:
  • Hearing loss (suggests tympanic membrane perforation, hemotympanum, or ossicular injury) 3
  • Otorrhea or bleeding from ear canal (indicates canal laceration or TM perforation) 4, 3
  • Tinnitus or vertigo (raises concern for inner ear injury) 3
  • Jaw pain or difficulty opening mouth (suggests TMJ injury or mandibular fracture) 1, 2

Physical Examination

Otoscopic examination is the critical diagnostic step 1, 2:

• Inspect external ear and periauricular area: Look for hematoma, laceration, or ecchymosis suggesting direct trauma 5
• Examine ear canal: Assess for lacerations, hematoma, foreign debris, or swelling 5
• Evaluate tympanic membrane:
  • Perforation (visible hole, may have blood or clear fluid) 5, 3
  • Hemotympanum (blue/purple discoloration behind intact TM, suggests temporal bone fracture)
  • Erythema and bulging (suggests acute otitis media, though unlikely from trauma alone) 5
  • Normal appearance (suggests secondary otalgia from referred pain) 1, 2

Palpate temporomandibular joint: Have patient open/close mouth while palpating anterior to tragus; pain or clicking suggests TMJ injury 1, 2

Assess mastoid area: Tenderness, swelling, or ecchymosis over mastoid (Battle's sign) suggests temporal bone fracture

Diagnostic Algorithm Based on Findings

If Ear Examination is ABNORMAL (Primary Otalgia):

Ear canal laceration with minor bleeding:

• No intervention needed; bleeding typically self-limited 4
• Do NOT insert cotton swabs or objects into canal 4
• Antibiotic drops NOT routinely needed unless infection develops 4

Tympanic membrane perforation:

• Keep ear dry; avoid water entry 3
• Most heal spontaneously within weeks 5
• Consider ENT referral if no healing after 2-3 months or if hearing loss persists 5

Hemotympanum or suspected temporal bone fracture:

• Obtain CT temporal bones (high-resolution, thin cuts) to evaluate for fracture
• Immediate ENT consultation
• Assess for CSF leak (clear otorrhea, halo sign on gauze)

Traumatic otitis externa (canal edema, erythema):

• Clean debris gently 6
• Topical quinolone drops (ofloxacin or ciprofloxacin-dexamethasone) twice daily for 7-10 days 6

If Ear Examination is NORMAL (Secondary Otalgia):

Evaluate for referred pain sources 1, 2:

• TMJ syndrome (most common in adults): Jaw tenderness, limited opening, clicking 1, 2
• Dental trauma: Examine teeth for fracture, loosening, or malocclusion 1, 2
• Cervical spine injury: Palpate cervical spine for tenderness; assess range of motion 2
• Pharyngeal injury: Examine oropharynx for hematoma or laceration 1

If no source identified and pain persists:

• Trial of NSAIDs for 48-72 hours 2
• If no improvement, consider imaging (CT or MRI) to evaluate for occult fracture 1, 2

Red Flags Requiring Immediate Imaging or Consultation

• Vertigo, severe hearing loss, or tinnitus: Suggests inner ear injury; obtain temporal bone CT and urgent ENT referral 3
• Clear otorrhea: Possible CSF leak from temporal bone fracture; CT imaging and ENT consultation 5
• Facial nerve weakness: Indicates temporal bone fracture with facial nerve involvement; immediate ENT consultation
• Battle's sign or hemotympanum: CT temporal bones to rule out basilar skull fracture
• Persistent severe pain despite normal exam: Consider occult fracture; obtain CT head/temporal bones 1

Common Pitfalls to Avoid

• Do not assume infection without signs: Trauma alone does not require prophylactic antibiotics 4
• Do not miss TMJ injury: This is the most common cause of secondary otalgia in adults and easily overlooked 1, 2
• Do not delay imaging for hemotympanum: This finding mandates temporal bone CT to exclude fracture
• Avoid aminoglycoside ear drops: If drops are needed, use only quinolones to avoid ototoxicity 6