Pediatric Annals

THE EAR AND HEARING 

Management of Traumatic Auricular Injuries in Children

Ralph E Holmes, MD

Abstract

Traumatic auricular injuries of children are managed by the same basic principles that apply to all wounds, with special consideration added for the anatomy and tissue composition of the ear. Projecting from the side of the head and easily deformed, the ear is readily injured by lateral head trauma. Thin skin is tightly adherent to cartilage that is dependent on nutrient diffusion from the skin. Thus, trauma to the ear has an immediate effect on the structurally supporting cartilaginous framework that defines its contour. Fortunately, the vascularity of the ear is rich, and with careful management many auricular injuries will heal satisfactorily.

The initial assessment of a child with an auricular injury should be comprehensive. It should include examination of the ear canal, the tympanic membrane, and auditory and facial nerve function and determination of the presence of contamination or a foreign body, as well as examination of the auricle itself. The viability of the tissues must also be assessed. In the neonate, the facial nerve is more susceptible to transection. As the mastoid process enlarges, the exit of the facial nerve moves interiorly and deep to the mastoid process by age 6, taking it further from harm's way.1 Although the auricle can be readily anesthetized using local infiltration around the ear and in the lateral canal, general anesthesia may be considered for the child's comfort. This may allow a more thorough examination, and a more detailed repair. Each pediatrician should set the point at which referral is made for the treatment of a given ear injury. Even if the pediatrician does not personally care for these injuries, some knowledge of the process will help him or her in working with the surgeon and educating families when such an injury occurs.

In most primary auricular repairs, suture techniques should be kept simple, using skin sutures of fine 6-0 nylon or polypropylene. Debridement of wound edges is usually not required and should be minimal if employed. If cartilage approximation is not achieved with skin sutures, a fine resorbable suture, such as 7-0 polyglactin, may be used in the perichondrium if the wound is minimally contaminated and copiously cleansed.

Dressings of the auricle are employed for protection of wound closures, maintenance of skin apposition to cartilage, and retention of topical ointments where indicated. The dressings can range from a simple layer of impregnated gauze that will allow frequent changing and inspection to a form-fit, otoplasty-type dressing where less frequent inspection and more protection is desired (Fig. 1).

SECONDARY DEFORMITIES

The most common secondary or residual deformities are notching or indentation of the scar, distortion of cartilage shape, and residual defect due to loss of tissue.11 Notches and indentations can be corrected by secondary revision to reapproximate the underlying cartilage and thereby support the overlying skin. Distortion of cartilage shape, if due to soft tissue constriction, may be improved by using new skin coverage from grafts or flaps. Deformity due to loss of cartilage can be corrected by chondrocutaneous flaps, cartilage grafts from the contralateral ear, and rib cartilage sculptured into an auricular framework with coverage by a temporoparietal fascia flap.12

SUMMARY

Management of traumatic auricular injuries in children does not differ qualitatively from that in adults. The more common, simple injuries in children can be as readily treated by their pediatricians as those in adults are by their primary care physicians. However, children are more likely to need general anesthesia for significant repairs. A comprehensive initial assessment of the injury site remains the foundation for treatment planning. An appreciation for the variety of treatment options available for the injured ear should facilitate…

Traumatic auricular injuries of children are managed by the same basic principles that apply to all wounds, with special consideration added for the anatomy and tissue composition of the ear. Projecting from the side of the head and easily deformed, the ear is readily injured by lateral head trauma. Thin skin is tightly adherent to cartilage that is dependent on nutrient diffusion from the skin. Thus, trauma to the ear has an immediate effect on the structurally supporting cartilaginous framework that defines its contour. Fortunately, the vascularity of the ear is rich, and with careful management many auricular injuries will heal satisfactorily.

The initial assessment of a child with an auricular injury should be comprehensive. It should include examination of the ear canal, the tympanic membrane, and auditory and facial nerve function and determination of the presence of contamination or a foreign body, as well as examination of the auricle itself. The viability of the tissues must also be assessed. In the neonate, the facial nerve is more susceptible to transection. As the mastoid process enlarges, the exit of the facial nerve moves interiorly and deep to the mastoid process by age 6, taking it further from harm's way.1 Although the auricle can be readily anesthetized using local infiltration around the ear and in the lateral canal, general anesthesia may be considered for the child's comfort. This may allow a more thorough examination, and a more detailed repair. Each pediatrician should set the point at which referral is made for the treatment of a given ear injury. Even if the pediatrician does not personally care for these injuries, some knowledge of the process will help him or her in working with the surgeon and educating families when such an injury occurs.

In most primary auricular repairs, suture techniques should be kept simple, using skin sutures of fine 6-0 nylon or polypropylene. Debridement of wound edges is usually not required and should be minimal if employed. If cartilage approximation is not achieved with skin sutures, a fine resorbable suture, such as 7-0 polyglactin, may be used in the perichondrium if the wound is minimally contaminated and copiously cleansed.

Dressings of the auricle are employed for protection of wound closures, maintenance of skin apposition to cartilage, and retention of topical ointments where indicated. The dressings can range from a simple layer of impregnated gauze that will allow frequent changing and inspection to a form-fit, otoplasty-type dressing where less frequent inspection and more protection is desired (Fig. 1).

Figure 1. Otoplasty-type dressing. Moist cotton balls are placed into the recesses of the ear, covered with fluffed up gauze sponges, and wrapped with a gauze roll.

Figure 1. Otoplasty-type dressing. Moist cotton balls are placed into the recesses of the ear, covered with fluffed up gauze sponges, and wrapped with a gauze roll.

Figure 3. Hematoma. Incisional drainage with gauze packing was required for a hematoma involving more than half the length of the ear.

Figure 3. Hematoma. Incisional drainage with gauze packing was required for a hematoma involving more than half the length of the ear.

BURNS

The depth of thermal injury to an auricle is related to the intensity and duration of the causative agent. Additional factors that can increase the initial depth include external trauma by friction or pressure, and the development of infection. The deeper the injury, the greater the likelihood of cartilage involvement. This can lead to chondritis, scarring, distortion, or loss of part of the ear.2 Mild burns with minimal erythema or superficial blistering can be treated by the pediatrician, using outpatient care consisting of elevating the head, washing the ear several times a day, and frequently applying an antimicrobial ointment. Any auricular burn of moderate degree has the risk of skin loss and chondritis and should be evaluated by a burn specialist to determine the need for inpatient care, intravenous antibiotics, debridement, and skin coverage (Fig. 2).3

Figure 2. Burned ear. This second-degree flame burn required skin grafting to avoid hypertrophic scarring and contraction.

Figure 2. Burned ear. This second-degree flame burn required skin grafting to avoid hypertrophic scarring and contraction.

CONTUSIONS

Blunt trauma to the ear is common in contact sports and falls. It may cause bleeding that separates the skin and the perichondrium from the cartilage, resulting in the accumulation of a hematoma. Physical signs include ecchymosis, tenderness, and localized or diffused swelling, according to the extent of the hematoma formation. Left untreated, the hematoma may (1) become infected and lead to chondritis, (2) deprive the cartilage of its diffusional nutrition and lead to necrosis, or (3) organize into dense fibrous tissue and lead to loss of normal auricular contour and detail.4

The goals of treatment are to remove the hematoma and to maintain apposition of skin and cartilage to avoid reaccumulation of fluid.5 For small hematomas, aspiration under aseptic conditions followed by the application of a contoured dressing may be performed by the pediatrician or the surgeon. Recurring collections or larger collections exceeding one-third of the ear should be treated with incision of the skin, evacuation of the blood, and the use of compression bolsters maintained with mattress sutures (Fig.3).6

Figure 4. (A) Complex ear laceration preoperatively. This boy was taken to the operating room for careful repair under general anesthesia and optimal conditions. (B) Four weeks postoperatively. Survival and healing of the lacerated fragments frequently results despite their small intact attachments.

Figure 4. (A) Complex ear laceration preoperatively. This boy was taken to the operating room for careful repair under general anesthesia and optimal conditions. (B) Four weeks postoperatively. Survival and healing of the lacerated fragments frequently results despite their small intact attachments.

LACERATIONS

Lacerations sustained by the auricle range from the simple linear cut by a sharp edge to the complex stellate-burst injury of blunt trauma. The lacerated segments may have broad attachments with intact blood supply or they may be tenuously attached with a compromised blood supply. Because segments may survive with even the smallest of attachments, it is generally best to be conservative with debridement until time reveals what is or is not viable.

The goals of treatment are to minimize contamination by thorough cleansing of the wounds, to restore shape and contour by accurate approximation of the wounds, and to provide protection during the healing phase with bandages.7 With simple lacerations of skin only, meticulous closure with 6-0 nylon sutures will serve well. Antibiotic ointment will suffice for bacterial coverage. When the cartilage is also lacerated, 7-0 polyglactin sutures may be required if the cartilage remains displaced or overlapped. Systemic antibiotics are preferred when cartilage injury is present.

Complex lacerations of the ear are best taken to the operating room, where brighter lighting, better instrumentation, and stationary positioning of the ear can contribute to a superior outcome (Fig. 4). The use of magnification loupes can be valuable in the determination of proper realignment of complex lacerations. Solutions containing epinephrine are strictly contraindicated due to the need to evaluate and maintain as much circulation as possible. Good surgical judgment is required in the application of a bandage that will protect the ear without impairment of a tenuous blood supply.

AVULSIONS

An avulsion injury of the auricle may be partial thickness with loss of skin only, or full thickness with loss of skin and cartilage. As with all injuries of the auricle, a comprehensive initial examination is required for optimal planning of treatment. If the viability of any remaining tissue is in question, it is best to wait a few days for declaration to take place. The wound can be covered with moist dressings and inspected daily. Partialthickness avulsion can be managed by skin grafting if perichondrium remains. Bare cartilage can be fenestrated to provide a vascular bed for skin grafting. Cutaneous flaps may also be used. For full-thickness avulsion injuries that are small, conversion to a wedge and primary closure may suffice (Fig. 5). More extensive defects require composite grafts or chondrocutaneous flaps, often as a secondary procedure (Fig. 6). Any avulsion injury of the auricle should be evaluated by a surgeon experienced in ear reconstruction.8

The most extensive auricular injury, total avulsion, has been the subject of a variety of treatment efforts. If the avulsed ear is not significantly damaged, it should be cooled (but not frozen) and sent to the emergency room with the patient. Simple reattachment with skin sutures, combined with cooling, dextran, heparin, and stab incisions, has met with a high failure rate. Denuding or dermabrading the ear and burying it in a retroauricular skin pocket has been more successful, although distortion of the final reconstructed ear is common.9 Microvascular replantation can give an excellent cosmetic result, if successful. A recipient site free of extensive injury and a skilled microsurgical team is required due to the small caliber of blood vessels and their low flow rate.10

Figure 5. (A) Full-thickness avulsion injury preoperatively. This young adult sustained a human bite injury. The avulsed segment, 20 to 30 mm long, is shown in the upper left corner of the photo. (B) Full-thickness avulsion injury immediately postoperatively. Simple reattachment was performed, but the segment failed to survive despite cooling and daily heparin injection directly into the segment.

Figure 5. (A) Full-thickness avulsion injury preoperatively. This young adult sustained a human bite injury. The avulsed segment, 20 to 30 mm long, is shown in the upper left corner of the photo. (B) Full-thickness avulsion injury immediately postoperatively. Simple reattachment was performed, but the segment failed to survive despite cooling and daily heparin injection directly into the segment.

Figure 6. (A) Full-thickness avulsion injury preoperatively. A 1 0-year-old girl lost the upper half of the ear in a motor vehicle accident. (B) Full-thickness avulsion injury 1 year postoperatively. Costochondral graft covered with temporoparietal fascia flap and skin graft has restored shape and form to the ear.

Figure 6. (A) Full-thickness avulsion injury preoperatively. A 1 0-year-old girl lost the upper half of the ear in a motor vehicle accident. (B) Full-thickness avulsion injury 1 year postoperatively. Costochondral graft covered with temporoparietal fascia flap and skin graft has restored shape and form to the ear.

SECONDARY DEFORMITIES

The most common secondary or residual deformities are notching or indentation of the scar, distortion of cartilage shape, and residual defect due to loss of tissue.11 Notches and indentations can be corrected by secondary revision to reapproximate the underlying cartilage and thereby support the overlying skin. Distortion of cartilage shape, if due to soft tissue constriction, may be improved by using new skin coverage from grafts or flaps. Deformity due to loss of cartilage can be corrected by chondrocutaneous flaps, cartilage grafts from the contralateral ear, and rib cartilage sculptured into an auricular framework with coverage by a temporoparietal fascia flap.12

SUMMARY

Management of traumatic auricular injuries in children does not differ qualitatively from that in adults. The more common, simple injuries in children can be as readily treated by their pediatricians as those in adults are by their primary care physicians. However, children are more likely to need general anesthesia for significant repairs. A comprehensive initial assessment of the injury site remains the foundation for treatment planning. An appreciation for the variety of treatment options available for the injured ear should facilitate an interaction between the pediatrician and the surgeon when injury is complex and should lead to the best outcome for each child.

REFERENCES

1. Allison GR. Anatomy of the external ear. Clin Plast Surg. 1978;5:419-422.

2. Grant DA, Finley ML, Coers CR. Early management of the burned ear. Plast Reconstr Surg. 1969;44:161-166.

3. Engrav LH, Richey KJ, Walkinshaw MD, Gottlieb JR. Chondritis of the burned ear: a preventable complication. Ann Plast Surg. 1989;23:1-2.

4. Stuteville OH, Janda C, Pandya NJ. Treating the injured ear to prevent a "cauliflower ear." Plast Reconstr Surg. 1969;44:310-312.

5. Gernon WH. The care and management of acute hematoma of the external ear. Laryngoscope. 1980;90:881885.

6. Savage R, Bevivino J, Mustafa G. Treatment of acute otohematoma with compression sutures. Ann Emerg Med. 1981;10:641-642.

7. Lawson W. Management of acute trauma. In: Lucente FE, Lawson W, Novick NL, eds. The External Ear. Philadelphia: W. B. Saunders; 1995:174-188.

8. Musgrave RH, Garrett WS. Management of avulsion injuries of the external ear. Plast Reconstr Surg. 1967;40:534-539.

9. Mladick RA, Carraway JH. Ear reattachment by the modified pocket principle. Plast Reconstr Surg. 1973;51:584587.

10. Turpin IM. Microsurgical replantation of the external ear. Clin Plast Surg. 1990;17:397-404.

11. Spira M. Early care of deformities of the auricle resulting from mechanical trauma. In: Tänzer RC, Edgerton MT, eds. Symposium on Reconstruction of the Ear. St. Louis, MO: C. V. Mosby; 1974:204-212.

12. Brent B. The acquired auricular deformity: a systematic approach to its analysis and reconstruction. Plast Reconstr Surg. 1977;59:475-485.

10.3928/0090-4481-19990601-11

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