Pierced Ear

Case Discussion

There are a few injuries affecting the ear that are important for EMS providers to be trained to manage and for which they should have protocols in place.

A child can injure the external ear, the pinna, with either a blunt or penetrating mechanism. The pinna is a very specialized structure, and any type of injury can end up damaging the cartilage that forms the external ear’s unique shape. Pinna injuries rarely bleed much, but pose a higher risk for infection. Of special note for EMTs is that if a pinna is partially amputated, any tissue that can be found should be transported to the ED. If a fragment is big enough, it may be replanted. Blunt injuries are very dangerous to the pinna. Any hematoma can break down the cartilage, resulting in a permanent deformity of the ear. Long-term deformity is called a cauliflower ear and is very common in wrestlers and others who sustain repeated blunt injuries to the pinna.

A child can also injure the ear canal or have an object in the ear canal that causes pain or other problems. A common emergency is when an insect of some type is in the canal. The presence of a live bug in the ear is very troubling to the patient and to parents. A simple and effective EMS management protocol would call for EMTs to fill the ear canal with a clean and viscous fluid, like mineral oil, K-Y jelly or vegetable oil. This will suffocate the insect, stop any movement and allow ED staff to eventually flush the insect out. Other objects in the canal, including beads, small parts of toys, small batteries and pieces of food, should be left alone until a physician can use appropriate tools in the ED to remove them safely. If the child complains of pain, some liquid lidocaine placed in the ear canal will begin to numb it.

A child can injure the eardrum, or tympanic membrane. This can occur from penetrating injury or with blunt injury. The patient may have pain and will be sensitive to sound. Either form of injury can cause bleeding, which is never severe unless a basilar skull fracture has occurred. Potential injuries to the eardrum should be transported with the patient in a head-elevated position and the injured ear facing downward to allow any blood to drip out.

A severe injury can occur when the inner ear is affected. The inner ear participates in both hearing and balance, and an injured inner ear will cause symptoms like hearing loss or intense ringing in the ear and dizziness. It can also cause an intense movement of one or both eyes, called nystagmus. This will cause some patients to complain of blurred vision or double vision and be very nauseated. Inner ear injuries are very rare, but again are usually managed by elevating the head and tilting the ear so the injured one drains outward.

Customer Service Opportunity

Children are extraordinarily adept at finding dangerous opportunities around them. Injuries can be very unpredictable. Unless an adult is present when it occurs, the history may not be very accurate.

Children’s caretakers and parents will get very distressed with painful or bloody injuries. It is ideal if the complete state of the injury is obvious to the EMS provider, and the parent or guardian can be reassured the child is going to do well. This happens in situations like lacerations from sharp objects that are completely visible to the EMT, where the bleeding is completely controlled and no deep structures like muscles, bones, blood vessels, nerves or tendons are injured. In these types of injuries, children and parents can be comforted and communicated with very directly: “I can see the entire injury, and the child is going to do well with a little bit of treatment.”

Much more difficult is when an injury cannot be fully evaluated, and the child and parents are very fearful for the child’s well-being. This case demonstrates an injury that cannot be evaluated in the field, where the EMTs will need to give a little assurance to the parents but not be able to say, “Everything will be just fine.” In this type of ear injury, it will even be difficult for the emergency physician to completely identify what is injured in the ear and what the long-term outcome of the child’s ear and hearing will be.