Ear Canal Trauma

A mother brought her 3-year-old child to the Emergency Department (ED) with the chief complaint of ear trauma. She stated that while attempting to clean the child’s ears with a cotton swab after his evening bath, he jerked away and the swab “went in too deep”. The child cried and was upset for several minutes. When he calmed down, Mom inspected the ear and noted blood coming from the canal. In the ED, the child was calm and cooperative with the evaluation. His external ear appeared atraumatic. The Wispr digital otoscope exam of his left ear is shown.

Which of the following is the best course of action?

A. Referral to ENT for tympanic membrane (TM) perforation
B. Provide prescription for oral antibiotics
C. Provide prescription for gentamicin ointment
D. Reassurance and pain control with OTC medications

This child has an injury caused by a common mechanism with a household item. The Wispr exam demonstrates bleeding in the external auditory canal (EAC) with a small amount of bright blood pooling near the base of the tympanic membrane (TM, eardrum). The TM itself does not appear acutely injured, as there is no obvious perforation, excoriation, or injection. Topical antibiotics are often indicated for auditory canal abrasions if there is a risk of infection from trauma, foreign body removal, or contamination. However, clean and superficial scratches in healthy people generally only need observation with careful return instructions to watch for increasing pain, drainage, fever, or decreased hearing. If the injury was deemed to be more severe, a topical fluoroquinolone would be the recommended choice.

The innocuous-appearing cotton-tip applicator (cotton swab) accounts for thousands of ED visits each year, with 2/3 of the injuries occurring in children under 8 years of age. Most injuries are either TM perforations or, as in this case, external ear canal (EAC) abrasions. While there exists a myth that waxy ears equal dirty ears, this is contrary to the message put forth by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Its list of do's and don'ts for patients includes "Do know that ear wax is normal” and "Don't put cotton swabs, hair pins, car keys, toothpicks, or other things in your ear." In other words, while cerumen may be an annoyance to all those attempting to evaluate a young child’s TM, care ought to be taken to dispel the misconception that cleaning out the ear canal ought to be a routine part of bath time.

Source:

Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. J Pediatr. 2017 Jul;186:124-130.

Here is a complete video of the exam: