Sports Injuries

Of the Ear G.A.WAGNER,MD

SUMMARY The author describes common sports injuries involving the ear. Such injuries include hematoma, lacerations, foreign bodies (tattoo), and thermal injuries. Ear canal injuries include swimmer's ear and penetrating injuries. Tympanum injuries include tympanic membrane perforations, ossicular discontinuity, eustachian tube dysfunction, temporal bone fractures and traumatic facial nerve palsy. Inner ear injuries include traumatic sensorineural deafness. The author emphasizes the management of these injuries. Dr. Wagner, an otolaryngologist, is on the active staff of three Calgary hospitals.

SPORTS INJURIES to the ear are as variable as the frostbite. These are usually found in skiers, skaters, and activities which cause them - they may involve the mountain climbers. Severe, deep frostbite injuries of the auricle, external auditory canal, tympanum, and inner ear, auricle are best treated by rapid rewarming with water- but only rarely involve the eighth cranial nerve or central soaked pledgets maintained at between 38 and 42 degrees auditory pathways. centigrade. Freezing, thawing, and re-freezing must be avoided since this is extremely injurious to tissue.2 Surgical Auricle debridement may occasionally be required but is generally Auricle injuries are common, as there is a human reflex prohibited for several months as the auricle has an amazing tendency to turn the head to the side when expecting capacity for self repair. frontal head trauma. The auricle is thereby involved even though the impact may have been from a head-on External Auditory Canal direction.' Lacerations in the ear canal, if minor, may be treated The so-called 'cauliflower ear' often seen in retired with an antibiotic-steroid eardrop solution in order to boxers or wrestlers is caused by untreated - or repeated - minimize crusting, maximize clot dissolution and cleansing hematomas of the auricle. A poorly-fitting helmet worn by of the ear canal, and help to prevent infection and irritating football or hockey players may also cause this injury. The inflammatory reaction. When there are circumferential treatment of choice is incision and drainage with three lacerations, the canal must be packed until healing has small incisions made within the helical folds, and elastic begun, after first carefully closing the laceration. Ribbon band drains brought out through these openings to be gauze impregnated with antibiotic ointment should be removed within four or five days. Antibiotic coverage while packed firmly into the canal and left in place for two weeks the drains are in place is useful to prevent cellulitis with the to prevent canal stenosis. Fractures of the anterior canal possibility of perichondritis. wall due to mandible injuries must be recognized and Lacerations and avulsions of portions of the auricle can treated early. Temporal bone fractures may involve a be repaired primarily up to 12 hours following the injury, fracture of the roof of the ear canal with, occasionally, a with good results mainly because of the excellent blood cerebrospinal fluid leak and herniation of brain tissue. This supply to the auricle. Careful closure in layers will suffice condition is a contraindication to application of topical for most lacerations. Avulsions or partial avulsions of parts solutions to the ear canal, and should be treated with of the auricle may be treated primarily by direct approxi- application of a sterile dressing, hospitalization, monitoring mation, composite grafts, or local flaps. Delayed or of neurological signs, prophylactic antibiotics, and may multiple-stage procedures are required for subtotal or total require definitive repair by a craniotomy. loss of the auricle in order to obtain a satisfactory result. 'Swimmer's Ear', or external otitis, while not caused by Thorough cleansing of the site of traumatic injury is trauma, is frequently an injury the ear sustains secondary to essential not only to avoid bacterial contamination but also swimming.3 Unclean water such as found in certain ponds, to remove gross debris. Foreign debris impregnated into lakes, rivers, and even swimming pools, is responsible. denuded tissue will be covered by a one or two cell layer of Irritants from algae, fungi (particularly Aspergillus Niger), epithelium and show through, causing 'debris tattooing'. and chemical irritants such as chlorine, are responsible for This debris must be removed thoroughly as soon as setting up the initial inflammatory reaction. The injury is possible. compounded by self inflicted trauma such as scratching or Thermal injuries to the auricle include sunburn and attempting to clean the ear canal. The patient presents with

CANADIAN FAMILY PHYSICIAN/JULY, 1972 51 a painful, tender, itching, often swollen and discharging ear acute stage, and/or retraction of the tympanic membrane, a canal. There may be a reactive dermatitis of the auricle. meniscus or fluid level or bubbles, or an amber or off-color Treatment includes thorough cleansing of the ear canal, tympanic membrane. Auto-inflation of the tympanum is ruling out an otitis media or mastoiditis, and initially usually not possible. The tympanic membrane has absent or instilling a quarter-inch wick of ribbon gauze soaked in one decreased mobility when tested with the pneumatic percent aluminum acetate solution (Burrow's Solution). otoscope. This acts as a hydrophilic colloid in withdrawing water Medical treatment includes oral antihistamine-decon- from the edematous ear canal. Strong analgesics are usually gestant preparations, and vasoconstrictor nose drops. necessary. Antibiotics are only useful if there is an Management of underlying causative conditions such as associated cellulitis or if one is uncertain about an allergy, nasopharyngeal tumors, and chronic rhinosinusitis associated otitis media. Follow-up care lasts usually one to is mandatory. A myringotomy, or myringotomy and two weeks and involves frequent cleaning of the ear canal insertion of a pressure equalization tube through the and instillation of topical ear drops, the type specific to the tympanic membrane, may be necessary. Temporal bone organisms cultured. fractures are of two types - longitudinal and transverse. Prevention of "Swimmer's Ear' mainly involves thorough The longitudinal petrous fracture is caused by a blow to the drying of the ear canal with a clean towel after swimming. side of the head such as might involve a boxer, or a hockey or lacrosse player. This causes a fracture of the thin Tympanum squamous portion of the temporal bone that then runs Tympanic membrane perforations may occur whenever through the longitudinal axis of the petrous bone, tearing there is a sharp blow to the ear canal. This occurs usually in the tympanic membrane and dislocating the ossicular chain. sports where helmets are not worn, such as water polo. The The transverse petrous fracture is caused by a much more great majority of these will heal spontaneously within a few severe blow to the back of the head, such as might happen months, although a few that don't heal may require a graft. to a figure skater who falls directly backward striking the Swimming or diving should be avoided not only because of occipital part of the skull on the ice. This fractures the the risk of causing a middle ear infection, but also in order heavy bones at the base of the skull and runs transversely to avoid the caloric effect of cold water.4 through the petrous bone, in many cases destroying the The main complication of a tympanic membrane per- inner ear and sometimes damaging the facial nerve. foration is infection, and if this occurs it is treated with The longitudinal petrous fracture is characterized topical steroid-antibiotic drop solutions, and parenteral clinically by bleeding from the ear, conductive deafness, antibiotics. Failure of the perforation to heal within three and positional vertigo. The deafness, if present three to four to six months is an indication for tympanoplasty in order months after the injury, is due to ossicular discontinuity to avoid ingrowth of squamous epithelium from the and can be corrected by surgery. perforation margins with subsequent cholesteatoma and The transverse petrous fracture is characterized clinically chronic ear disease. by hemotympanum usually with an intact tympanic Ossicular discontinuity is a complication of temporal membrane, sensorineural deafness, spontaneous nystagmus bone fractures. There may be a hairline fracture of the beating toward the opposite ear, decreased caloric response petrous portion of the temporal bone that is unrecognizable on the involved side, and sometimes peripheral facial nerve on X-ray but the patient has a hemotympanum usually with palsy. bleeding from a tear of the tympanic membrane and a Oblique temporal bone fractures can also occur but are conductive hearing loss. Following absorption of the variants of the above two main types. Fortunately, the hemotympanum and healing of the tympanic membrane, longitudinal petrous fracture is four times as common as the conductive deafness persists. This is usually due to lack the transverse type. Management of these fractures is the of continuity between the long process of the incus and same as management of any skull fracture. Priorities must head of the stapes. Sometimes a notch can be seen at the be set for the entire patient. Attention must be given to bony annulus with the otoscope, indicating a fracture line. airway, blood loss, and associated chest and abdominal The treatment is surgery with restoration of ossicular injuries; neurological status must be continuously moni- continuity. tored. Prophylactic antibiotics are indicated, as these A severe blow to the ear may not only rupture the fractures, by communicating with the pharynx through the tympanic membrane but also force the stapes through the ear, are open fractures and considered contaminated. oval window into the inner ear, with consequent vertigo, mixed deafness, and bleeding from the ear. The treatment Facial Nerve Palsy for this injury is immediate tympanotomy with restoration Traumatic facial nerve palsy is an otologic emergency if of the ossicles to their normal position and grafting the oval present immediately after the injury. This requires explora- window fistula shut with living tissue. Such a condition, if tion of the facial nerve in its entire bony canal as soon as not treated early, would probably result in a permanently the patient's general condition permits. Often a spicule of damaged ear. bone will be found pressing on the nerve. This can be removed with good results. The nerve may be transected, in Eustachian Tubes which case it can be re-approximated or grafted, if a Eustachian tube insufficiency is a problem for scuba segment is missing. A diagnostic problem arises when the divers, skiers, and sky divers. Severe pain in the involved ear patient is not seen immediately after the injury or if he is at the time when the eustachian tube fails to equalize unconscious after the injury. This type of patient may have sudden changes in pressure is one identifying symptom. only a neuropraxia or temporary damage to the nerve due Other symptoms are a feeling of fullness in the ears, to edema following the injury. Nerve conductivity studies tinnitus, and decrease of hearing. Otoscopic examination are helpful in differentiating good and poor prognosis in may show inflammation of the tympanic membrane in the facial nerve paralysis.

52 CANADIAN FAMILY PHYSICIAN/JULY, 1972 Inner Ear Treatment is prophylactic. Well-fitted ear plugs are best Sensorineural hearing loss secondary to acoustic trauma but the seal must be tight. Ear plugs plus ear muffs provide in sports hunters or any sportsmen using firearms is the best sound protection with attenuation of 40 db. up to common.5 Skeet and trap shooters have the greatest 2,000 cps., and 60 db. at 4,000 cps. Dry cotton in the ears exposure to acoustic trauma. Noise levels below 80 db. are is useless for sound protection. harmless, whereas exposure to SPL greater than 130 db. are Sensorineural hearing loss associated with diving to painful to the ear, and this exposure is known to cause depths of 20 to 30 feet has been reported.7 The etiology is irreversible changes. The peak sound level of a 12 gauge unknown but those divers who develop hearing losses at shotgun at the ear of the shooter is 140 db., which is frequency levels of 4,000 Hz or 6,000 Hz probably should dissipated to 110 db. in 0.2 seconds. not dive, or, if they do continue, should have audiograms at three-month intervals. Symptoms of Acoustic Trauma Acoustic trauma symptoms are tinnitus, fullness in the Central Pathways ear, diplacusis, and deafness. The hearing loss is initially Post-concussion vertigo is very common. It is usually temporary but, with prolonged noise exposure, becomes positional and transitory. The treatment is symptomatic.< permanent. The loss is a high frequency one which impairs ability to hear sibilant and soft consonant sounds. Word discrimination is impaired. A hearing aid is not helpful for this type of deafness. References Noise damage to hearing comes from excessive move- 1. GROSS, C W., Otol. Clinics ofN.A., 292-302, June, 1969. ment of the cochlear partition, thereby producing mechani- 2. SESSIONS, Donald G., et al, Laryngoscope V. 81: 1223-1231, cal damage which results in degeneration of the hair cells 1971. and supporting structures. This in turn causes secondary 3. JONES, Edley H., Laryngoscope V. 81: 731- 733, 1971. of the associated neural elements. 4. BUTTERFIELD, Donald E., et al, New Engl. J. Med. V. 269: degeneration Spiral 147-149, 255-259, 1963. ganglion cells and peripheral nerve fibers are also damaged.6 5. TA YLOR, G. D., et al, Laryngoscope V. 76: May, 1966. A sudden explosion such as a gun blast causes the same 6. WARD, W. D., Otol. Clinics ofN.A., 89-104, February, 7969. damage to the ear as a severe head blow. 7. SOSS, Siedell, Arch. Otolaryng. V. 93: 501-504, 1971.

QUOTE Each person ought neither to be unacquainted with the peculiarities of his own pulse (for there are many individual diversities) nor ignorant of any idiosyncrasy which his body has in regard to temperature and dryness, and what things in actual practice have proved to be beneficial or detrimental to it. For the man has no perception regarding himself, and is but a blind and deaf tenant in his own body, who gets his knowledge of these matters from another, and must inquire of his physician whether his health is better in summer or winter, whether he can more easily tolerate liquid or solid foods, and whether his pulse is naturally fast or slow. For it is useful and easy for us to know things of this sort, since we have daily experience and association with them. - Plutarch, Moralia, "Advice About Keeping Well" trans. F. C. Babbit

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