Most sports and many occupations and recreational activities have their share of injuries to the external ear. Even in mandatory-helmet sports, lacerations and abrasions are seen. These may be due to an opponent's fingernail or a player bending the ear during the placement of a helmet. This latter injury may not be uncomfortable at first, but after hours of practice, the folded ear may swell and bleed at the crease, producing intense pain and many months of sensitivity.

Cauliflower Ear

While cauliflower ear has in past years been commonly associated with boxing, its incidence is much higher in wrestling. The condition itself is the result of untreated or poorly treated hematoma. The clinical picture progresses from (1) injury to the ear causing persistent, throbbing pain that lasts long after the causative event, (2) possible fibrocartilage fracture, (3) swelling, local heat, tenderness, followed by the development of a hematoma after several hours, initially between cartilage and overlying skin, visible to the naked eye, (4) tissue hardening and the development of early fibrous tissue in about 14 days, and (5) the resulting keloid mass, development of new cartilage, and permanent deformity of the external ear characterized by skin wrinkling, thickening, and contraction at the site of injury.

Professional Care.   First-aid consists of ice packs and pressure bandages during the healing stage. Hirata condemns straightforward incision, although a common practice, as it opens the area to secondary infection, chondritis, and perichondritis due to the relative avascularity of the cartilage. Referral for aspiration, several drainings if need be, is preferred. Following aspiration, some authorities recommend irrigating the aspirated area with a solution of hyaluronidase to reduce swelling and edema of injured tissues. Several trainers have found that hyaluronidase is more effective if "driven in" with iontophoresis or phonophoresis.

After aspiration, or even if aspiration is not necessary, a pad of folded gauze about 2-inches thick, covered with collodion, should be applied to the bruised ear and supported by an ace bandage. Before the pressure pad is applied, a loose plug of cotton should be inserted within the middle and exterior thirds of the external canal. The pressure pad should remain in place for 3-5 days in which time daily monitoring is made to assure the swelling is subsiding. Prevention lies essentially in the use of proper head gear, but care must be taken that the ear cap is properly fitted or this in itself creates a hazard.

External Ear Disorders Associated with Water

Otitis Externa.   External otitis (swimmer's ear) is commonly seen in competitive surface swimmers. The cause is a breakdown of the normal cerumen barrier due to constant exposure to warm water. Itching and discharge are the first symptoms. Infection in the skin of the external auditory canal quickly leads to inflammation, erythemia, edema (which hides the drum), acute tenderness, and a mild cellulitis that matures rapidly to a firm furuncle that is extremely painful and tender, usually requiring antibiotics and sedation. Each attack destroys some cerumen glands, which encourages further attacks.

A chronic mild itching encourages "ear picking" which tends to spread the infection. Diffuse otitis externa is typically a bacteria, fungi, or allergic disorder. Pool work must be restricted until healing is complete. Many otolaryngologists recommend careful monitoring of the pool chlorine content and the instilling in each ear of half-strength Burrow's solution after each pool session to prevent infection. Others suggest a commercial antifungal preparation or a solution of 90% isopropyl alcohol and 10% vinegar or 5% glacial acetic acid for irrigation.

External Barotrauma.   During a diving descent below 30 feet when the ear is protected by ear plugs or a hood, a negative pressure develops that causes the drum to bulge outward, usually without discomfort or rupture. Capillaries within the external canal may break to form small blisters in the skin of the exterior canal to present a roughened surface. People so afflicted should be advised to avoid scuba diving. If diving is continued, some help can be obtained by avoiding ear plugs or cutting a hole in the hood to allow water to enter the exterior ear.

Exostoses.   Exostoses are another affliction often seen in swimmers, especially cold water swimmers, which often predispose to otitis externa. The superior aspect of the canal just lateral to the pars flaccida of the drum is a favorite site of these benign bony tumors of the exterior canal. They are neither the cause nor the effect of the otitis directly. They are usually asymptomatic and rarely cause complete canal blockage, but they do encourage otitis externa because they interfere with cerumen passage and inhibit water within the ear to drain outward. Ear plugs may help in prevention and avoid continued growth, but surgical removal may be necessary.

Miscellaneous Disorders of the External Ear

Insects in the Ear.   An uncommon but frightening experience is an insect buzzing within an ear. Treatment can be provided by placing the patient in the side position with the affected ear up and syringing or pouring warm vegetable oil or water into the external auditory meatus. This will usually float out the insect.

Lacerations.   In any case of laceration of the pinna, secondary infection is always a danger due to the poor resistance of the relatively avascular cartilage exposed. Appropriate care must be made to avoid permanent and ugly scarring.

Canal Collapse.   Due to relaxation of soft-tissue support, the medial end of the condral cartilage may drop forward to narrow the lateral end of the external canal. The resulting slit can easily be opened with a speculum, but normal cerumen passage is inhibited, leading to infection and possible otitis externa.

Trauma-Related Middle Ear Disorders

Hearing depends upon the integrity of the external canal, the drum, the air chamber of the middle ear, the windows, the mobile chain of ossicles, the auditory nerve, and the perceptive higher centers in the brain. Any abnormality of one or more of these factors can impair hearing. Treatment of most all middle-ear disorders consists of keeping the ear dry (difficult with swimmers and divers), using preventive irrigation, using an appropriate therapy to decongest the tissues, managing any infection present by appropriate means, and seeking otologic consultation when necessary.

Middle-Ear Barotrauma.   In rapid pressure changes such as in diving or an airplane descent, the drum herniates inwardly if the eustachian tube does not afford pressure equalization. The negative pressure within the middle ear causes slight hemorrhages and extracts fluids from adjacent tissues. A weakened drum may rupture in a deep descent, resulting in severe vertigo as water enters the middle chamber. Prevention is made by avoiding clogged ears or nasal congestion prior to descent. When on the surface, a diver may help unblock an eustachian tube by laterally flexing the neck away from the affected side and pulling the pinna or skin of the neck up and down on the affected side.

Alternobaric Vertigo.   Alternobaric vertigo sometimes occurs during a rapid diving ascent where eustachian tube blockage causes middle-ear pressure buildup. In severe cases, the drum may rupture. The associated rotary vertigo, vertical nystagmus, and severe disorientation may produce panic. An experienced diver will usually recognize the early signs of dizziness and slow his ascent accordingly.

Drum Perforation.   In addition to the barotraumatic forces described above, a concussive blow on the ear can result in traumatic perforation of the drum and possible ossicle damage. Special audiometric tests are usually required to determine the exact degree of resulting deafness. Slightly perforated drums usually heal spontaneously if kept dry. There is slight scar development. During healing, care must be taken while blowing the nose. Flying and deep diving should be avoided.

Ruptured Round-Window Membrane.   An aqueduct connects the cochlea and the subarachnoid space. In some people, this aqueduct is large enough to allow a free flow of cerebrospinal fluid within the scala tympani. As the aqueduct's opening is near the round-window membrane that separates the inner and middle ear, a forceful Valsalva maneuver or an attempt at autoinflation (causing transient increase in blood and cerebrospinal pressure) can transmit cerebrospinal fluid pressure to an extent to rupture the round window membrane. Once this occurs, fluid escape causes the hair cells to malfunction, the ear feels full or "dead," a loud tinnitus is perceived, deafness (unnoticed when under water) occurs especially with high tones, and vertigo and nausea usually manifest and are associated with spontaneous nystagmus and a staggering gait. During diagnosis, differentiation must be made from Meniere's disease or a viral infection of the middle ear.

Otitis Media.   Common earache is rarely trauma oriented; it is usually secondary to pharyngitis. Otitis media is the result of the normally air-filled middle ear chamber with an intact drum becoming filled with fluid because of impaired eustachian tube function. This is usually the result of an inflammation spreading from a sore throat via the eustachian tube. A feeling of fullness in the ear progresses to pain and a degree of deafness. As pressure builds within the chamber, the drum appears thick and red (blood) or yellow (pus) prior to possible rupture.

The common cause in swimmers is poor technique; ie, not expelling air when the nose is under water. Ocean, lake, or pool water irritates the nasal mucosa, resulting in nasal congestion and infection. For the same reason, scuba divers should never let water enter the mask. An ear where fluid leakage is seen should never be plugged, just lightly covered with a sterile pad.

Trauma-Related Inner Ear Disorders

Inner-ear disorders are characterized by vertigo, tinnitus, and hearing loss. Acute viral labyrinthitis is usually secondary from a cold or gastrointestinal infection, not trauma. Hearing loss is rarely associated, but vertigo is usually severe. It is usually self-limiting in 1-3 weeks.

Referred Earache.   A common cause of earache is often not within the ear itself but from the adjacent temporomandibular joint, especially in gum-chewers and brace-wearers having subclinical arthralgia of this joint. Chronic tonsil, pharynx, or larynx inflammations are also common causes of referred pain to the ear. Other causes include cervical subluxation, sternomastoid and masseter trigger points, dental problems, and an abnormally long styloid process.

Inner-Ear Barotrauma.   Injury to the inner ear is usually of an intrinsic nature as it is well protected by surrounding bone. Impairment is usually the result of abnormal pressure changes or fistulae.

Meniere's Syndrome.   The syndrome features endolymphatic hydrops from pressure changes in inner-ear fluids. Symptoms include paroxysmal dizziness, tinnitus, and a degree of deafness. The latter two may originate unilaterally and progress to both ears. It is often secondary to a number of metabolic disorders, but a common cause (primary or secondary) often overlooked is a cervical or upper thoracic subluxation. Differentiation must be made from CNS vertigo and benign paroxysmal postural vertigo.