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Auricular Hematoma

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Other Names

  • Auricular Hematoma
  • Cauliflower ear

Background

  • This page refers to auricular hematomas, typically seen after blunt trauma to the external ear

History

  • Described in athletes during the original Roman olympic games (need citation)

Epidemiology

  • Dalal et al[1]
    • Study of 87 patients with auricular hematoma
    • 40% came from sports injuries
    • Assaults and falls accounted for 10% each
    • The rest from self harm, iatrogenic/ post-operative

Intrtoduction

An auricular hematoma
Anatomy of the external ear[2]

General

  • Caused by direct blow or frictional forces to the auricle
  • Hematoma forms between the skin and auricular cartilage
  • Hematoma causes pressure necrosis and scarring of the cartilage causing deformity ("cauliflower ear")

Anatomy of the External Ear

  • Complex, convoluted cartilage framework with tightly adherent overlying skin
  • Three main parts: helix/antihelix, concha and lobule
  • Anterior surface is susceptible to trauma because of tight adherences to underlying perichondrium and lack of subcutaneous fat
  • Blood supply comes from the posterior auricular artery, superficial temporal artery

Pathophysiology

  • Hematoma forms in the space between the perichondrium and cartilage of the anterior of the ear[3]
  • Scarring process involves subperichondrial hematoma is invaded by chondrocytes, fibroblasts, leading to fibrocartilage formation
  • Blood supply dependent on perichondrium, allowing for complications such as infection and cartilage necrosis
  • If left untreated, cauliflower ear can develop as a result of stimulation of the mesenchymal cells

Risk Factors

  • Failure to wear headgear while participating in sports that can cause ear trauma
    • 1989 survey of US collegiate wrestlers: 52% of athletes who did not wear headgear vs 26% of athletes who did wear headgear[4]
  • Male > female (need citation)
  • Sports
    • Wrestling
    • Boxing
    • Combat Sports
    • Rugby
  • Other causes
    • Assault, falls
    • Self harm
    • Iatrogenic/ Post operative
  • Systemic conditions
  • Anticoagulation
    • Increases the risk of spontaneous auricular hematoma

Differential Diagnosis


Clinical Features

History

  • Patients typically describe some type of trauma
  • Athletes report pain, swelling, tenderness and paresthesia
  • Ear fullness, pressure
  • Difficulty hearing
  • In severe cases, bleeding from the external auditory canal
  • Headache, dizziness have been reported

Physical Exam

  • Perform a thorough exam of the external ear, understand normal anatomy
    • Compare to unaffected ear
  • Look for swelling, ecchymosis, erythema, fluctuance
  • Hematoma of Auricle on physical exam
  • Tenderness over hematoma
  • Asymmetry compared to opposite auricle

Evaluation

Clinical Diagnosis

  • Diagnosis made on physical exam and history of trauma to ear; No labs or imaging useful in diagnosis
  • Evaluate for clinical signs of Auricular Hematoma on physical exam
  • Assess patient's hearing and evaluate tympanic membranes as may rupture with trauma to ear
  • Assess for signs and symptoms of concussion

Imaging

  • Not indicated routinely
  • CT imaging may be appropriate if skull fracture or cervical spine imaging is a consideration
  • MRI may be appropriate in persistent neurological symptoms
  • Skull radiographs can evaluate for foreign body

Classification

  • Not applicable

Management

Auricular block technique illustration[5]
Auricular hematoma before and after aspiration[6]
Demosntration of the compression dressing using suture material and dental rolls[7]
  • Numerous options have been proposed
  • Optimal and effective treatment remains controversial
  • Consensus that hematoma must be drained to prevent cauliflower ear

Auricular Hematoma Aspiration

  • Sterilize the site
  • Provide local anesthesia with lidocaine without epinephrine
    • Consider auricular block
  • Aspirate with 18 to 22 gauge needle
    • Simple aspiration is thought to often be insufficient
    • The hematoma should be "milked" during aspiration
  • Alternatively, incise and drain with a #13 or #15 blade
    • Orient the incision parallel to the creases of the pinna can help with cosmetics
    • Irrigate with sterile saline
  • Injectates
    • Proposed to stimulate adhesion of the dead space
    • OK-432 (Picibanil) to stimulate local inflammation
    • Corticosteroids to induce vasoconstriction, reduce extravasation

Compression Dressing

  • Apply compression dressing to avoid reaccumulation of hematoma (keep in place until healed)
    • Many techniques/ dressings have been proposed in the literature
    • Consider: dental roll, silastic splint, xeroform, buttons
    • Duration recommended for 5 to 7 days
  • Simple pressure dressing
    • Use 3 cm gauze wrap or dental rolls to occupy any void spaces
    • Place anteriorly and posteriorly
    • Conform to natural contour of the skin
  • One study left a catheter in place to facilitate drainage[8]
  • Mattress suture technique
    • Absorbable sutures are used to close the hematoma and hold it together
    • This has largely replaced the button technique
    • One study found mattress sutures superior to iodoform gauze placement (need citation)
  • Thermoplastic splints
    • Easily made by occupation or physical therapists
  • Magnet Technique
    • Used successfully in this case report[9]
  • Other proposed techniques include
    • Silicon
    • Fibrin Glue

Additional Considerations

  • Consider preventive antibiotics covering gram-positive skin bacteria (Cephalexin x 7 days)
  • Avoid NSAIDs and Aspirin to minimize hematoma recurrence
  • Tetanus vaccine is indicated if not up to date

Rehab and Return to Play

Rehabilitation

  • Not typically necessary

Return to Play/ Work

  • Auricular Hematoma should be fully healed prior to return to play
  • Patient should be referred to ENT for close follow-up
  • Returning prior to being fully healed increases risk of poor outcomes
  • Headgear should always be worn

Prognosis and Complications

Cauliflower ear as a result of a chronic auricular hematoma[10]

Prognosis

  • Needs to be updated

Complications

  • Cauliflower ear
    • Cosmetic deformity, often undesirable
    • Involves the auricle's anterior surface
    • Difficult to correct surgically[11]
  • Cartilage necrosis
  • Scarring and cosmetic deformity
  • Chondritis and Perichondritis
  • Superinfection
  • Abscess

See Also


References

  1. Dalal PJ, Purkey MR, Price CPE, Sidle DM. Risk factors for auricular hematoma and recurrence after drainage. Laryngoscope. 2020 Mar;130(3):628-631
  2. Image courtesy of teachmenanatomy.info
  3. Sellami M, Ghorbel A. Traumatic auricular hematoma. Pan Afr Med J. 2017;26:148.
  4. Schuller DE, Dankle SK, Martin M, Strauss RH. Auricular injury and the use of headgear in wrestlers. Arch Otolaryngol Head Neck Surg. 1989 Jun;115(6):714-7
  5. Image courtesy of https://tidsskriftet.no/en/2017/01/auricular-haematoma
  6. Image courtesy of motionismedicine
  7. Ganti, Latha, ed. Atlas of emergency medicine procedures. Springer Nature, 2022.
  8. Brickman, Kris MD; Adams, Daniel Z. MD; Akpunonu, Peter BS; Adams, Samuel S. BS; Zohn, Stephen F. MD; Guinness, Michael MD Acute Management of Auricular Hematoma, Clinical Journal of Sport Medicine: July 2013 – Volume 23 – Issue 4 – p 321-323 doi: 10.1097/JSM.0b013e31825c4623
  9. Haik, Josef, et al. "Cauliflower ear–a minimally invasive treatment method in a wrestling athlete: a case report." International medical case reports journal (2018): 5-7.
  10. Niknafs, Nichole. "Cauliflower Ear Secondary to a Chronic Auricular Hematoma." Journal of Education and Teaching in Emergency Medicine 3.4 (2018).
  11. Vogelin E, Grobbelaar AO, Chana JS, Gault DT. Surgical correction of the cauliflower ear. Br J Plast Surg 1998;51: 359–362
Created by:
John Kiel on 12 June 2019 16:17:35
Last edited:
10 June 2024 23:10:35
Categories:
Trauma | HEENT | Acute