Auricular hematoma

Background

  • Caused by blunt trauma to external ear
    • Associated with contact sports such as boxing, wrestling, etc.
  • Separation of perichondrium from underlying cartilage tears the adjoining blood vessels[1]
    • Usually occurs on anterior surface, since skin is firmly adherent to cartilage (on posterior ear, there is underlying muscle and adipose is it loosely adherent to cartilage)[2]
    • Recurrent hematomas lead to infection and/or cartilage necrosis and neocartilage formation (i.e. "cauliflower ear")
    • Goal of treatment is to prevent "cauliflower ear" deformity by draining the hematoma in a timely fashion

Clinical Features

  • Gross deformity/swelling to pinna after recent blunt trauma
  • Loss of typical auricular landmarks/anatomy[3]
  • Pain out of proportion[3]
  • Hematoma most commonly collects in the scaphoid fossa and the concha

Differential Diagnosis

Ear Diagnoses

External

Internal

Inner/vestibular

Maxillofacial Trauma

Evaluation

  • Clinical diagnosis

Management

Indications for drainage[4]

  • Traumatic swelling that deforms pinna
  • Within 7 days of trauma

Contraindications

In these cases, refer to ENT due to formation of granulation tissue that may require debridement

  • Recurrent or chronic hematomas
  • > 7 days from trauma

Procedure

  1. Perform an auricular block
  2. Evacuate the clot
    • Option 1: Make semi-circle incision inside the inner curvature of the helix or antihelix
      • Make incisions along natural auricular crease for cosmesis
      • Remove hematoma by milking of the hematoma toward the incision. Suction or curettage may also be helpful
      • Use a butterfly hemostat or suture kit needle driver to break up any hematoma that is not easily coming out
    • Option 2: Use large-bore needle/syringe to aspirate hematoma[2]
      • Needle aspiration generally is not sufficient treatment[3], especially for larger hematomas as clot has usually already formed and cannot be aspirated
  3. Prevent re-accumulation of hematoma (goal is to close the dead space between perichondrium and cartilage[1]). Multiple methods available:
    • Option 1: Compression dressing
      • Pack the helix with petroleum jelly-impregnated gauze
      • Place regular gauze both in front of and behind the ear
      • Circle the head with a compressive wrap
      • Generally only moderately successful, and subject to poor compliance (especially with athletes[1])
      • Alternative to petroleum jelly gauze is to splint the ear with a molded piece of plaster [5] [6]which fits better and does not need as tight of a compression dressing.
    • Option 2: Suture
      • Use fast-absorbing sutures
      • Place running or interrupted sutures through cartilage and both anterior and posterior skin of auricle in mattress fashion[2]
      • This should reappose the perichondrium
      • Consider leaving incision open (with wound edges approximated by mattress sutures) to allow for continued drainage[1]
    • Option 3: Bolster sutured in place- combination of the above two methods
      • Use non-absorbable 2-0 or 3-0 nylon
      • Pack the helix with petroleum jelly impregnated gauze. Place a thick layer of gauze behind the ear
      • Perform a running quilt stitch through the anterior gauze, through the pinna, and through the posterior gauze
  4. Antibiotics
    • Often used by our ENT colleagues in all patients though it is actually only recommended for immunocompromised patients
    • Cover pseudomonas and S. aureus- Cipro is the most commonly used

Disposition

  • Discharge
  • ENT followup in 2-3 days for suture removal or dressing removal and wound check

See Also

  • Maxillofacial Trauma

References

  1. Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol. 2010 Jan-Feb;31(1):21-4.
  2. Vuyk HD, Bakkers EJ. Absorbable mattress sutures in the management of auricular hematoma. Laryngoscope. 1991 Oct;101(10):1124-6.
  3. Giles WC, Iverson KC, King JD, Hill FC, Woody EA, Bouknight AL. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007 Dec;117(12):2097-9.
  4. Laybell I et al. Auricular Hematoma Drainage. Aug 7, 2015. http://emedicine.medscape.com/article/82793-overview#a8
  5. Trick of the Trade: Splinting the ear from AliEM https://www.aliem.com/trick-of-trade-splinting-ear/
  6. Ear Lacerations, Part II from Lacerationrepair.com https://lacerationrepair.com/techniques/anatomic-regions/ear-lacerations-part-ii/
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