All Service Members that develop symptoms consistent with noise trauma (acute tinnitus, muffled hearing, fullness in the ear) should be educated and directed to self-report for evaluation and possible treatment as soon as practicable. Patients exposed to hazardous noise occurring from exposure to battle (improvised explosive devices, rockets, and small arms fire) and all patients exposed to a blast should be asked specifically about hearing loss and tinnitus during their initial trauma evaluation, unless other more urgent treatment or mental status conditions do not allow. This should be documented as soon as safe evaluation permits. All patients presenting to concussion care centers should be evaluated for hearing loss and tinnitus. If there is debris in the External Auditory Canal (EAC) or in the middle ear (as seen through a TM perforation), treat the patient with a fluoroquinolone and steroid containing topical antibiotic (e.g., four (4) drops of ciprofloxacin/dexamethasone or ofloxacin in the affected ear three (3) times a day for seven (7) days). Do NOT irrigate the ear as it may provoke pain and vertigo, move debris medially in the canal and middle ear, and promote infection. Also, do not use any topical drops containing aminoglycosides (i.e. the neomycin in Cortisporin) since these are ototoxic. Patients should observe strict dry ear precautions and keep ALL water out of the EAC until the TM perforation has healed or is repaired. Removal of debris should only be done by an ENT surgeon in order to avoid further injury to the EAC or the middle ear.
Hearing loss that persists 72 hours after acoustic trauma warrants a hearing test or audiogram. When hearing loss is present, individuals should be restricted from hazardous noise environments and kept on base, if possible. This is important to allow time for healing, and the inner ear is more susceptible to further noise-induced damage while it is under the oxidative stress and glutamate toxicity of an acute injury. A Service Member with hearing loss is less effective during missions and can negatively impact mission performance.
Vestibular trauma to the inner ear may manifest in vertigo. Please refer to the Veteran Affairs/DoD vestibular clinical recommendations for a detailed review of traumatic dizziness (http://hearing.health.mil/files/vestibclinpractrecs.pdf). All patients with positional vertigo and without other contraindicating injuries should undergo a Dix-Hallpike test, and an Epley or canalith repositioning maneuver if positive. (See Appendix A and Appendix B.)