What is the management approach for an infant with ear trauma?

Management of Ear Trauma in Infants

For infants with ear trauma, immediately assess for tympanic membrane perforation and middle ear involvement using pneumatic otoscopy, evaluate hearing status, and determine whether the injury is external (pinna/canal) or internal (middle ear), as this dictates whether conservative management versus urgent otolaryngology referral is required. 1, 2

Initial Assessment and Diagnosis

Physical Examination Priorities

• Perform pneumatic otoscopy to visualize the tympanic membrane and determine if there is perforation, middle ear fluid, or visible ossicular damage 1, 2
• Document the laterality of injury, as bilateral ear injuries in infants under 1 year are extremely rare and should raise concern for non-accidental trauma 3
• Examine for external injuries including lacerations, hematomas, or thermal injury to the pinna 4, 5
• Blood in the external auditory canal warrants careful evaluation for tympanic membrane perforation or middle ear injury 6, 3

Critical Red Flags

• Infants under 1 year with ear trauma are uncommon in accidental injury (only 1% of cases), and such presentations warrant heightened suspicion for non-accidental trauma 3
• Penetrating trauma can cause ossicular chain disruption, presenting with hearing loss, vertigo, or ataxia 6
• Visible ossicles through a perforation indicate significant middle ear injury requiring urgent otolaryngology consultation 6

Management Based on Injury Type

External Ear Injuries (Pinna/Canal)

• Auricular hematomas require immediate evacuation and pressure dressing to prevent cartilage necrosis and "cauliflower ear" deformity 4, 7
• Simple lacerations should be closed using aseptic technique with skin-to-skin sutures; complex lacerations require meticulous fragment matching and ensuring all cartilage is covered with vascularized tissue 4, 5
• Chondritis is the most feared complication and requires aggressive management with prompt removal of necrotic cartilage and antibiotic therapy 4

Middle Ear Injuries

• Any infant with suspected middle ear trauma (perforation, ossicular injury) requires urgent otolaryngology referral for potential middle ear exploration 6, 5
• Penetrating injuries causing ossicular disruption may require surgical reduction of subluxed ossicles 6
• Obtain tympanometry using a 1000-Hz probe tone to objectively assess middle ear status in infants 1

Hearing Assessment Protocol

Immediate Evaluation

• All infants with ear trauma require hearing assessment, as trauma is a risk factor for delayed-onset or progressive hearing loss 1
• For infants under 6 months developmental age, use frequency-specific auditory brainstem response (ABR) testing with air-conducted and bone-conducted tone bursts 1
• For infants 6-36 months, the test battery should include behavioral audiometry (visual reinforcement or conditioned-play), otoacoustic emissions (OAE), and ABR if behavioral responses are unreliable 1

Follow-Up Monitoring

• Infants with ear trauma should have at least one diagnostic audiology assessment by 24-30 months of age, even if initial screening is normal, as trauma is a recognized risk factor for progressive hearing loss 1
• Document any parental concerns about hearing, as any parental concern requires objective hearing screening 1

Referral and Coordination

Otolaryngology Consultation

• Immediate referral is required for: tympanic membrane perforation with visible ossicles, suspected ossicular chain disruption, auricular hematoma requiring drainage, complex lacerations, or any penetrating middle ear injury 6, 5
• Otolaryngologists should act promptly and be versatile in repair methods to reduce morbidity 6

Medical Home Coordination

• The primary care physician must ensure audiological assessment is completed and monitor for delayed complications 1
• Close developmental surveillance is essential, as 30-40% of children with confirmed hearing loss demonstrate developmental delays or other disabilities 1
• Flag the medical record to facilitate tracking and follow-up 1

Common Pitfalls to Avoid

• Do not delay hearing assessment in trauma patients, as early identification of hearing loss enables intervention within critical developmental windows 1
• Avoid aminoglycoside-containing ear drops if tympanic membrane perforation is suspected due to ototoxicity risk 2
• Do not dismiss bilateral injuries or injuries in very young infants (<1 year) as accidental without thorough evaluation for non-accidental trauma 3
• Auricular hematomas must not be observed—they require immediate drainage to prevent permanent deformity 4, 7