37
Ear, Nose, and Throat
Injuries in Abused Children
Philip V. Scribano, DO, MSCE, and Russell A. Faust, PhD, MD, FAAP
INTRODUCTION
Children who sustain injuries from abuse often experience
trauma to the face, mouth, and neck regions. An estimated
50% to 75% of abused children have injuries in these loca-
tions,1-5 with a higher prevalence in the younger child or
infant. In a large case series of over 1248 children evaluated
for all types of abuse and neglect, 37.5% included injuries
to the head, face, mouth, or neck. The prevalence increased
to 75.5% when the investigators evaluated only those chil-
dren who became involved with the child protective services
system for suspected physical abuse.2
The high prevalence of injuries to the face and neck sup-
ports the concept that the relative easy accessibility to that
part of the body as well as the psychological importance of
these areas predisposes them as frequent targets for the
offender trying to silence a crying child.2,6-8
Despite the frequency of face and neck injuries, there is
a relatively low prevalence of injuries to the mouth (2%).2,6,9
This could be due to medical providers’ unfamiliarity with
examining the oral cavity. In addition, given the rapid
healing potential of mucus membranes, oral injuries might
resolve before being identified by a medical provider. While
some abusive injuries can be severe and life threatening,
most face, mouth, or neck injuries reported in the literature
are less serious. Nevertheless, these findings can be harbin-
gers of significant risk for more severe and repeated trauma
if not detected as such.1,3,10-12 Therefore, it is paramount
that abuse-related injuries are promptly recognized. Table
37-1 lists common otolaryngological injuries caused by
abuse.
FACIAL INJURIES
The face is the most frequently injured area of the body from
physical abuse. Abrasions and bruises comprise most (87%)
of the injuries, whereas lacerations account for 6% to 7%.4
Abusive facial injuries are most often caused by a hand
punching or slapping the oro-facial region or by an object
impacting the face. The most common sign of open-hand
blows to the face is multiple parallel marks representing the
fingers (Figure 37-1). Bruising to the cheeks or anterior neck
region (Figure 37-2) is suspicious for abuse, since this soft
tissue does not overlie any bony prominence and therefore
requires significant impact for ecchymoses to occur. The risk
of accidental injury to the face is similar to that for the head
332
and scalp, with the greatest risk existing for young children
who are learning to crawl and walk.
Facial fractures in children are rare and should prompt
a high index of suspicion for abuse unless the circumstances
of the trauma are sufficiently credibile.13,14 Facial fractures
are known to result from motor vehicle accidents, from falls
of significant heights, and from traumatic deliveries of new-
borns.15 Mandible fractures are quite rare in infants and
would not be expected to occur after a short household fall.16
Given this fact, any infant presenting with a fractured man-
dible should be evaluated for possible child abuse if a major
accident has not been confirmed.
EAR INJURIES
Ear injuries prompting suspicion of abuse include any lac-
erations of the external auditory meatus or hematomas,
ecchymoses, or bruises of the auricle. Bruising to the pinna,
which includes anterior as well as posterior injury, is highly
suggestive of pinching or grabbing of the ear (Figure 37-3).
Evidence of tympanic membrane perforation or ossicular
discontinuity is especially suspicious; this can result from a
forcible slap to the external ear with an open hand. Ulti-
mately, chronic, recurring trauma can result in deformation
of auricles17,18 as well as sensorineural hearing loss.3 Penetrat-
ing trauma can cause injury to the external auditory meatus,
tympanic membrane, and middle ear.1 The classic triad of
unilateral ear bruising, retinal hemorrhages, and ipsilateral
cerebral edema with obliteration of the basilar cisterns and
associated subdural hemorrhage describes the tin ear syn-
drome.19 In the original case report, three children under 3
years of age had similar bruises of the antitragus, the helix,
and the triangular fossa, and in the interior folds of the ear
without other bruises or lacerations of the head, external
auditory meatus, or tympanic membranes. The three chil-
dren died as a result of their abusive head trauma which
included uncal herniation. On autopsy, ipsilateral subdural
hemorrhage with absence of coup or contra coup injury was
noted. The postulated mechanism was blunt trauma to the
side of the head impacting at the point of the ear, which
resulted in significant rotational acceleration of the head.
These injuries point out the importance of ear bruises in
children as a sign of possible associated injuries. Another
type of ear injury, recurrent auricular hematomas (“cauli-
flower ear”) is common in boxers, but unusual in other sports
and extremely rare in accidental trauma.
 CHAPTER 37 EAR, NOSE, AND THROAT INJURIES IN ABUSED CHILDREN 333

Otolaryngological Injuries
Table 37-1
Suspicious for Abuse
Ear
• Auricular hematoma/ecchymoses
• Laceration of external auditory canal
• Tympanic membrane perforation
• Ossicular discontinuity
• Total hearing loss associated with vertigo
• Facial nerve paresis
• Cerebral spinal fluid otorrhea
• Persistent otitis media with effusion

Nose
• Recurrent epistaxis
• Septal deviation/perforation
• Columella destruction
• Impaired naso-maxillary development
• Foreign body insertion with internal nasal trauma
• Cerebral spinal fluid rhinorrhea

Oropharynx
• Bruising of the palate or fauces
• Lacerations or evidence of foreign body trauma
• Dental avulsion/subluxation
• Burns to lips or oral mucosa
• Abrasions or scars at the lip, commissures
• Labial frena tear FIGURE 37-1 A 3-year-old boy with characteristic, hand slap bruise
• Vocal cord paralysis over the right cheek.

Other Injuries/ Conditions

• Facial/mandibular fractures
• Retropharyngeal soft tissue neck trauma
• Functional hearing loss
• Vocal cord nodules
• Lesions consistent with sexually transmitted diseases

Of particular concern is any injury associated with total

hearing or balance loss, facial nerve paralysis, or cerebro-
spinal fluid (CSF) otorrhea (or CSF rhinorrhea). These inju-
ries should prompt additional evaluation to determine the
circumstances of injury, since accidental injuries of the ear
and associated neurological structures are uncommon.3 It
can be challenging to distinguish perforation of the tym-
panic membrane caused by infection and rupture from the
perforation caused by trauma; the presence of hemotympa- FIGURE 37-2 An 8-year-old who reported being choked by an adult
num in the absence of purulence should prompt greater while being sexually abused. Patterned finger marks support the
scrutiny and consideration of an abusive episode. Facial history of choking.
nerve paresis combined with any other evidence of trauma
warrants a computerized tomography (CT) scan of the tem-
poral bone to rule out fracture. Similarly, cerebrospinal identified a high level of salivary amylase, proving the “ear
fluid otorrhea, even as an isolated finding, is cause for sus- discharge” to be saliva. Clinicians were able to recognize
picion. It can reflect a blow of significant force, resulting in this as a case of factitious illness, but only after multiple
either temporal bone fracture or rupture of the membra- evaluations, surgical intervention (myringotomy), and hos-
nous inner ear. pital admissions. An astute nurse recognized that the
It is important to recognize that falsification of symp- “symptom” only occurred with the mother was alone with
toms of ear disease has been described.20 One case involved the child. Other otolaryngological manifestations of facti-
a mother who reported that her 8-month-old infant had tious illness have been reported, such as persistent cerebro-
recurrent, at times, bloody discharge from his external spinal fluid otorrhea, sinusitis, hearing loss, and apnea
auditory meatus. An analysis of the fluid from the ear caused by suffocation.21-25
334 SECTION V PHYSICAL ABUSE OF CHILDREN
A
B
FIGURE 37-3 A 7-year-old girl with inflicted bruises on her left pinna.
A, Anterior view. B, Posterior view.
NASAL INJURIES
Accidental injuries to the nose are not uncommon. Intrana-
sal injuries, however, should prompt suspicion, since these
injuries require significant force. In addition, although chil-
dren commonly insert foreign bodies into their noses, associ-
ated injury to intranasal structures is rare and when
encountered, abuse should be considered.26 Examination
findings such as recurrent epistaxis, blood clots, or deviation
of the nasal septum are not diagnostic of abuse, but the
history should include a reasonable mechanism of injury.
Blunt force trauma to the nose with nasal cartilage fracture
and resulting septal hematoma will lead to resorption of the
cartilage with perforation and possible nasal deformity if not
managed acutely. The findings of septal perforation or colu-
mella destruction can be sequelae of old, untreated injuries.
Hematoma and abscess of the nasal septum resulting in nasal
deformity and other complications have been described as
resulting from child abuse.27 In general, the nose does not
bruise without direct impact or pinching. Nasal tip or colu-
mella bruising is highly suspicious for intentional injury from
pinching these structures.
ORAL INJURIES
Signs of abuse in the oral cavity can be subtle and difficult
to recognize if the clinician is not conducting a thorough
examination. A comprehensive examination should include
FIGURE 37-4 A 4-year-old boy who reported being burned with a
kitchen spoon. He sustained intra-oral and commissure burns; the
posterior pharynx was spared.
FIGURE 37-5 A 6-week-old infant who was admitted with burns to
the face and oral mucosa after being fed a bottle of milk overheated in
a microwave.
inspection of the hard and soft palates, labial and lingual
frena, gingiva, tongue, buccal mucosa, posterior pharynx,
and teeth if present. Injury to the lips is the most common
abusive injury to the mouth.13 Repeated trauma can leave
scars over the lips. Localized abrasions or bruises to the
commissures suggest injury from a mouth gag. Burns to the
mouth and commissure can be caused by application of
heated implements to the mouth, such as a heated spoon
(Figure 37-4). Burns to the mouth and lips also can be due
to unintentional events (Figure 37-5). A torn labial frenum
has been regarded as pathognomonic of abuse in non-ambu-
latory children.2,6,8,28,29 A frustrated caregiver trying to silence
a crying infant using a hand or other object such as a bottle
can result in these lesions (Figure 37-6). Oral (buccal) lacera-
tions or bruising of the palate in a young, pre-ambulatory
child is highly suspicious for abuse and can result from the
forcible insertion of an object into the mouth or from a direct
blow to the mouth. The oral cavity is also a site for identify-
ing sexual abuse trauma. Lesions can result from sexually
transmitted infections. Petechiae and bruising at the junction
of the soft and hard palates or on the floor of the mouth can
be caused by forced fellatio.6,13 Injuries to the tongue have
 CHAPTER 37 EAR, NOSE, AND THROAT INJURIES IN ABUSED CHILDREN
FIGURE 37-6 A 7-week-old with an upper labial frenum laceration.
(Courtesy of Jonathan Thackeray, MD, Columbus, Ohio.)
resulted from an adult biting an infant’s tongue. The arc of
the bite (the concave surface of the mark) in the direction
toward the lips instead of toward the posterior pharynx sug-
gests the injury is the result of non-accidental trauma rather
than self-inflicted injury.30 Because of the healing character-
istics and excellent blood supply of the mucus membranes,
oral lacerations rarely require surgical repair.
Teeth can be injured and result in fracture, avulsion,
luxation, or displacement. Although fractures are more
likely to be the result of accidental trauma, it is important to
obtain a detailed history to understand the cause of these
injuries. Tooth avulsions caused by abuse (direct force apical
to the crown of the tooth, resulting in expulsion of the tooth)
are almost exclusively limited to the anterior teeth because
of their single root structure, where a sufficient blow to the
alveolar ridge of the mouth can result in this trauma.8 Forced
dental extraction by parents as a form of child abuse has
been reported where intact teeth were forcibly removed
from a child’s mouth while the child was restrained.31 Luxa-
tion, or disruption of the tooth causing injury to the peri-
odontal ligament supporting the tooth in the alveolar ridge,
can present as a loose tooth and can be displaced lingually
(more likely in abusive events) or labially because of an
object or hand strike to the mouth and teeth.
NECK/PHARYNGEAL INJURIES
Pharyngeal/hypopharyngeal injuries, which should prompt
further evaluation for possible non-accidental trauma,
include hypopharyngeal laceration, esophageal perforation,
and retropharyngeal hematoma with associated cervical
spine and cervical cord trauma (Figure 37-7).10,11,32,33 These
injuries result from forcible insertion of foreign objects and/
or hyperextension/hyperflexion of the neck, and character-
istically present with an inconsistent or absent history to
explain the injuries. Often, there has been a delay in seeking
care. Symptoms include hemoptysis, noisy breathing, diffi-
culty feeding, drooling, stridor, or subcutaneous emphy-
335
FIGURE 37-7 CT scan of the neck of a 2 12 -month-old with bilateral
femur fractures. Skeletal survey revealed a calcification on lateral neck
x-rays. The CT scan identified a resolving retropharyngeal calcified
hematoma adjacent to a C5 compression fracture and epidural
hematoma. This prior injury was correlated with a period of respiratory
difficulty approximately 3 weeks before the study.
sema.34 Evidence of enlargement of the retropharyngeal
space, retropharyngeal air, or pneumomediastinum is some-
times found on imaging studies.
Vocal cord paralysis (unilateral or bilateral) can be caused
by strangulation or can result from a severe head injury.
Patients present with respiratory distress, stridor, choking
spells, or frank apnea.33 In one report, a 13-month-old child
was co-sleeping with her mother. The mother had very long
hair, and the child was strangled accidentally by her
mother’s hair.35 Specific indicators of possible strangulation
include laryngeal edema, hyoid bone fracture, petechiae
of the neck and face, and ligature marks on the neck. At
autopsy, findings of fat necrosis with subsequent calcification
in the soft tissues of the neck (necklace calcification), Tar-
dieu’s spots (subpleural ecchymoses following death from
strangulation), and subintimal hemorrhage of the carotid
artery, have been described after strangulation, and they
should warrant high suspicion for non-accidental injury.36-38
In some cases, strangulation abuse leaves no identifiable
injury pattern.
STRENGTH OF
THE MEDICAL EVIDENCE
The medical evidence with regard to otolaryngologic inju-
ries in abused children consists of multiple case reports and
case series that demonstrate characteristic injury patterns in
maltreated children. As such, it provides a growing evidence
of certain injuries commonly occurring in abused children.
There is little literature, however, comparing inflicted and
accidental injuries. Such studies would facilitate greater
diagnostic accuracy in determining the causes of injuries to
the face, nose, ears, mouth and pharynx.
SUGGESTED DIRECTIONS
FOR FUTURE RESEARCH
Future research efforts should focus on distinguishing char-
acteristics that assist the clinician in determining the mecha-
nism of injuries. There is a need for greater clinical and
diagnostic injury identification, especially in the oropharynx
and neck. Also, research on methods to improve the detec-
tion of occult injuries would improve clinical care.
336 SECTION V PHYSICAL ABUSE OF CHILDREN
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