Ear Bruising in a Newborn

Educational Objectives

• Subgaleal hemorrhages are rare but can be life-threatening due to the potential blood accumulation within the large subgaleal space.

• Bruising in a pre-mobile child and ear bruising in a child less than 4 years of age can be a sign of physical child abuse and may warrant further evaluation for abuse.

Case Report

A 5-day-old female infant with an unremarkable medical history presented with bruising behind both ears. Mother first noticed the retro-auricular bruising a day prior and mentioned it during an outpatient clinic visit. She had several prior normal physical examinations by her pediatrician without signs of bruising, including at the time of birth hospital discharge as well as follow-up visits for close monitoring of weight gain and jaundice. The family was referred to the emergency department after the clinic visit for further evaluation of bruising and jaundice.

Regarding birth history, she was born at 39 weeks and 2 days via spontaneous vaginal delivery to a 40-year-old, gravida 1 para 1, Group B Strep positive mother. She was born small for gestational age (2700 grams) with Apgar scores 8 and 9 at 1 and 5 minutes, respectively. She received vitamin K, Hepatitis B vaccine, and erythromycin eye ointment after birth. On nursery discharge examination, she was noted to have a left occipital swelling initially thought to be a cephalohematoma.

Physical examination showed a well-developed, well-nourished infant in no acute distress. She had a boggy left occipital swelling with ill-defined borders. Her eyes were equal, round, and reactive to light with no evidence of conjunctival hemorrhage. She had bruising along the nape of her neck communicating with bilateral retro-auricular bruising (Figures 1 and 2), left greater than right. Superior and inferior labial frenulum and frenulum linguae were intact without signs of injury. No other bruising, scars, rashes, or patterned injuries are noted.

Figure 1.

Right ear bruising of infant.

Figure 2.

Left ear bruising of infant.

Discussion

Hospital Course

Our patient was admitted briefly for further work-up which included normal coagulopathy work-up, normal hematocrit, mildly elevated bilirubin levels that were not at phototherapy threshold, normal skeletal survey without evidence of any fractures, and a head ultrasound ruling out any intracranial hemorrhages. A magnetic resonance imaging (MRI) with and without contrast depicted the subgaleal bleed along the left parietal region without any associated calvarial fractures (Figure 3), and the patient did not require neurosurgical intervention. After a detailed history, the mother reported rupture of membranes was spontaneous and 18 hours until birth. She was in active labor for several hours. Mother also noted the obstetrician mentioned the patient’s head was stuck on the left side during active labor. The initial birth examination concerning for cephalohematoma was more likely a subgaleal hemorrhage, both of which are hard to differentiate at birth. These extra details of the delivery course were reassuring against non-accidental trauma and better explained the presence of the subgaleal hemorrhage in the absence of a vacuum-assisted delivery.

Figure 3.

Magnetic resonance imaging of brain with and without contrast showing a crescentic subgaleal collection along left parietal region measuring up to 8 mm in maximal thickness without any associated calvarial fracture.

Discussion of Case and Literature

The differential diagnosis for retro-auricular bruising in this infant includes a basilar skull fracture, non-accidental trauma, and accidental trauma from birth. A basilar skull fracture is least likely in this case given absence of head trauma history after birth and other clinical manifestations, such as hemotympanum, subcutaneous bleeding around the orbit, and abnormal neurological examination. Non-accidental trauma had to be excluded given bruising is the most common finding of physical child abuse and often missed at initial presentation of abuse. It can be a subtle sign of abuse or “sentinel” injury that can precede more severe physical abuse and should evoke suspicion for possible abuse in all pre-mobile infants. ¹ Ear bruising has been evaluated as part of a clinical decision-making rule, also known as, TEN-4-FACESp. This acronym can help the clinician identify children at risk for having been physically abused by taking into account the child’s age as well as the bruising’s pattern and location. Bruising to “Torso, Ear, Neck (TEN), Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae (FACES), and patterned (p)” bruises in children less than 4 years of age, or any bruising in an infant less than 4.99 months of age would be worrisome. ² This has been validated in a prospective multicenter study and found to have good sensitivity (95.6%) and moderate specificity (87.1%) in discerning abusive trauma from accidental trauma. Therefore, this clinical decision-making rule is a useful screening tool to help identify bruising that warrants further evaluation for abuse.^2,3

Subgaleal hemorrhages are defined by a collection of blood in the space between the periosteum of the skull and aponeurosis. The subgaleal space is a large potential area that includes the orbital ridge anteriorly, the occiput posteriorly, and ears laterally and is not limited by suture lines. Newborns with subgaleal hemorrhages can therefore present with frontal, suboccipital, and retro-auricular ecchymoses, as seen in this case. ⁴ They are rare but potentially life-threatening due to the risk of significant blood accumulation within the subgaleal space. They are commonly found in assisted vaginal deliveries or vacuum-assisted deliveries and less commonly in spontaneous vaginal deliveries. Subgaleal hemorrhages after non-assisted vaginal deliveries are infrequent, but can have the same severe complications as assisted vaginal deliveries and should therefore be considered on the differential for birth-related extracranial injuries. ⁵

Subgaleal hemorrhages may be difficult to differentiate from other extracranial injuries from birth trauma. On examination, they are described as a “fluctuating mass” that can shift with movement and expand. ⁴ This contrasts with cephalohematomas that involve blood in the skull and periosteum. Cephalohematomas distinctively do not cross suture lines and rarely expand. Subgaleal hemorrhages can also be initially confused with caput succedaneum, which are swellings of the scalp above the periosteum and can therefore cross suture lines. Caput succedaneum tends to be less expansive and faster resolving than subgaleal hemorrhages. Figure 4 provides a schematic of the different layers involved in birth-related extracranial injuries. ⁶

Figure 4.

Sites of extracranial and extradural hemorrhages in the newborn. Schematic diagram of important tissue planes from skin to dura.

Although rare, severe complications can occur with subgaleal hemorrhages, including hypovolemic shock, coagulopathy, severe metabolic acidosis, seizures, apnea, and death.^7,8

Early detection and monitoring are key in preventing poor outcomes. Infants should be closely monitored for signs of blood loss, which includes pallor and tachycardia. Serial hematocrit checks and coagulopathy work-up should be considered. Head imaging, such as MRI or computed tomography (CT), may be useful in differentiating other cranial injuries if diagnosis is uncertain. Head ultrasound can be used as a noninvasive tool that can better describe the hemorrhage. An outpatient provider should closely follow the newborn’s physical examination and head circumference.

Treatment is based on the severity of presentation and primarily supportive. In severe cases, volume resuscitation may be necessary and blood products should be administered to correct anemia, thrombocytopenia, and coagulopathy that can occur as a sequela of the expanding hemorrhage.^4,9 Like other extracranial injuries in newborns, subgaleal hemorrhages can cause hyperbilirubinemia from increased bilirubin production from red blood cell breakdown. Bilirubin should be monitored closely to determine the need for phototherapy or exchange transfusion. Surgical intervention to evacuate subgaleal blood is rare and limited to case reports. ⁹

Final Diagnosis: It was determined that the retro-auricular bruising was secondary to a subgaleal hemorrhage from birth causing blood accumulation within the subgaleal space in this area.

Conclusion

Subgaleal hemorrhages are a rare complication of birth that can have severe sequalae. Differentiating them from other birth-related extracranial trauma can be difficult, but important in terms of further management and monitoring. Retro-auricular bruising is a rare physical examination finding in infants with subgaleal hemorrhages due to the expansive subgaleal space. Regardless, an infant with ear bruising should prompt consideration of further evaluation for child abuse.

Author Contributions

All authors contributed to writing and revising the manuscript.