Auricular Hematoma Cover

Cauliflower Ear: Causes and Treatment

introduction

Auricular hematomas are a frequent complication of blunt force trauma to the external ear, often seen in contact sports such as wrestling, boxing, and martial arts.  Sports medicine practitioners are likely to encounter auricular hematomas and should be comfortable with acute, subacute and chronic management.

The external ear is susceptible to external trauma because of its prominent location on the side of the head.  The adult ear is made up of a complex convoluted cartilage framework with tightly adherent overlying skin. The portions of the ear can be broken up into three main parts: helix/antihelix, concha, and lobule (Fig. 1). The anterior surface of the ear is susceptible to trauma, because it typically bears the brunt of applied impacts and because its skin is tightly adherent to the underlying perichondrium, due to the lack of subcutaneous fat.

Anatomy Ear

Image 1: Ear anatomy. Adopted from [14].

The blood supply to the external ear is derived from two interconnected systems via branches of the external carotid artery. The majority of blood supply is from the posterior auricular artery (PAA), which supplies the entire postauricular surface and the concha through perforators of the PAA. The anterior surface is supplied by the superficial temporal artery (STA), which gives a branch to the triangular fossa–scapha region via a sub branch of the superficial temporal artery

The pathophysiology through which auricular hematomas result in cauliflower ear is twofold. First, there is a disruption of the blood supply to the underlying cartilage, which results in cartilage infection and death. Second, there is cartilage loss and necrosis with formation of new cartilage and fibrous tissue.  Although there are various treatments that can prevent these complications and restore the auricle to its original form, delay in treatment can result in a conspicuous ‘‘cauliflower ear’’ deformity.

This “cauliflower ear” deformity is cosmetically undesirable and can be very difficult to correct, often requiring multistage procedures and multiple revisions. Untreated AH can also develop superinfection and/or an abscess requiring more emergent attention. Thus, early and effective drainage of an AH is critical [1].

Etiology auricular hematoma

Image 2.  Etiology and provider specialty breakdown.  Adopted from [8].

physical examination

Physical exam involves a thorough evaluation of external ear. It is important to have a good understanding of the baseline anatomy of the ear to better differentiate pathology. A focused physical exam includes an evaluation of the external ear, evaluation of the tympanic membrane with an otoscope, and evaluation for any coexistent lacerations or trauma of the head and neck. It is imperative to evaluate for facial nerve weakness as the facial nerve passes through the ear and can be damaged when there is trauma to the ear. Physical exam findings consistent with auricular hematoma include contour irregularity of ear with swelling and fluctuant area overlying the ear’s cartilaginous portions. Likely symptoms include pain, paresthesia, and ecchymosis.

treatment

A number of treatment options for auricular hematomas have been suggested, but a continuing controversy exists regarding the most effective therapy.  Complete evacuation of blood from the subperichondrial space and closure of any space between the perichondrium and the auricular cartilage are most important when treating auricular hematomas. Further, simple aspiration of the hematoma is typically an insufficient treatment method.

A number of treatment options for auricular hematomas have been suggested, but a continuing controversy exists regarding the most effective therapy.  Complete evacuation of blood from the subperichondrial space and closure of any space between the perichondrium and the auricular cartilage are most important when treating auricular hematomas. Further, simple aspiration of the hematoma is typically an insufficient treatment method.

Needle aspiration is a common technique used to evacuate the hematoma.  This is normally done in a clean manner with local antiseptic solution.  Lidocaine is used for local anesthetic and an 18 to 22 gauge needle is used for the aspiration.  While aspirating, the area should be expressed or “milked” to facilitate the removal of as much blood as possible. Once aspiration is complete, the area should be cleansed, direct pressure should be held for several minutes, and then a bolster or compression dressing applied.

Recent studies have suggested intralesional injection of chemical compounds such as OK-432 (Picibanil) to stimulate local inflammation and induce adhesion of the dead space, or of steroids to induce vasoconstriction and reduce extravasation of blood [2,3].  OK-432 therapy has been developed for patients with various otolaryngological cystic diseases, including a plunging ranula, a lymphatic malformation, a salivary mucocele, and a thyroglossal duct cyst [2].  

Formal incision and drainage (I&D) is normally performed with a number 13 or 15 blade and the prep is somewhat similar with the topical antiseptic and local anesthetic.  A great auricular nerve may also be performed for additional anesthesia.  An incision entering the plane between the perichondrium and cartilage is made over the hematoma at the site of greatest swelling and fluctuance.  Orienting the incision parallel to the cartilaginous creases of the pinna may help with cosmetics.  The area should then be irrigated with sterile saline solution.  Systemic antibiotics are recommended to cover for normal skin flora and pseudomonas if I&D is required [6,7]. Tetanus prophylaxis is recommended, if not up-to-date [6]. 

Sutures ear auricular hematoma

Image 3.  Mattress sutures.  Adopted from [18].

Several methods of preparing and applying a bolster dressing have been described in the literature, including the use of dental rolls, Silastic splints, Xeroform, and buttons, though none have definitely been found to be superior [8].  The simplest form is creating a pressure wrap with 3 cm gauze wrap or adding dental rolls to occupy any void spaces.  The rolls need to be placed anteriorly and posteriorly and conform the skin to its natural space [6].  In 53 wrestlers with a hematoma of less than 3 weeks of onset, an alternative approach utilized an 18-gauge angiocatheter to aspirate the blood. The site was manually expressed to facilitate drainage, the catheter was left in place, and the end trimmed once aspiration was complete [9].

After traditional I&D and irrigation, the mattress technique can be performed using absorbable sutures, which are placed through the pinna and auricle to approximate the wound edges. The goal is to maintain the normal curve of the auricle and restore natural folds, while preventing reaccumulation. Both sides of the wound are covered with a topical antibiotic ointment and a loose dressing applied.  This has replaced the button technique in many practices.

Newer techniques include using thermoplastic splints, silicon, fibrin glue and magnets.  Studies are somewhat limited with the newer techniques and mostly limited to case studies and case series.  Thermoplastic splints can be made by many occupational and physical therapists and can be used for days after drainage [10].  Magnets are readily available and can be worn for 2-7 days after drainage.  They can also be used for prevention if soreness and pain is felt by the patient or athlete [11].

Treatment bolster auricular hematoma

Image 4.  Comparison between bolster treatments and speciality referral.  Adopted from [8].

Giles et al compared various methods of managing auricular hematoma. They compared incision and drainage with absorbable mattress suture placement to simple needle aspiration and incision and drainage with iodoform gauze placement. They found that the incision and drainage with mattress suture showed the best results with only 1 in 19 (5.3%) experiencing hematoma recurrence.  The study by Brickman et al. also had a similar success rate [9].  A 2004 Cochrane review concluded that although there was insufficient evidence to recommend an optimal treatment strategy, the literature supported early identification and drainage of auricular hematomas over no treatment [13].

The sequelae of an untreated or inadequately treated auricular hematoma may include infection, cartilage necrosis, and the development of a cauliflower ear deformity. Such a deformity typically involves the auricle’s anterior surface, where the greater applied force and lack of a subcutaneous fat cushion result in injury to the perichondrium [14]. Few series address the actual treatment of cauliflower ear. In 1997, Lee and Sperling1 described excision of the fibroneocartilage associated with recurrent traumatic auricular hematoma with fair cosmetic results [15]. Vogelin et al. described treating three patients with cauliflower ear via a posterior approach with resculpturing of remaining cartilage resulting in an acceptable cosmetic result [16]. In 2002, Yotsuyanagi et al described shaving of cartilage through small incisions and the use of a postauricular flap if there was skin involvement. [17]. 

Summary

In conclusion, no matter the method used to resolve the hematoma, the goal is to prevent the reaccumulation of blood once the hematoma has been drained, as this is the cause of most complications. This ideally occurs within 6 hours and the bolstered dressing or sutures should be placed and follow up should be within a few days to ensure return does not occur.   Sports medicine providers can provide an outlet for the community and should be comfortable with acute care of auricular hematomas.

References

  1. Hao S, Angster K, Hubbard F, Greywoode J, Vakharia KT. Ear scaffold reconstruction using ultrasonic aspirator for cauliflower ear. Cleft Palate Craniofac J 2018;55:619–621.
  2. Hedges, B. Z., & Pearson, D. A. (2019). Otologic trauma. In J. J. Schaider et al. (Eds.), Rosen & Barkin’s 5-minute emergency medicine consult (6th ed.). Philadelphia, PA: Wolters Kluwer
  3. Kubota T, Ohta N, Fukase S, Kon Y, Aoyagi M. Treatment of auricular hematoma by OK-432. Otolaryngol Head Neck Surg 2010;143:863–866.
  4. Im GJ, Chae SW, Choi J, Kim YS, Kim WJ, Jung HH. Intralesional steroid injection for the management of otohematoma. Otolaryngol Head Neck Surg 2008;139:115–119.
  5. Ingulsrud, E. (2015). Auricular hematoma drainage. In K. H. Shah, & C. Mason (Eds.), Essential emergency procedures (2nd ed.). Philadelphia, PA: Wolters Kluwer.
  6. Campo, T. M., & Lafferty, K. A. (2015). Essential Procedures for Emergency, Urgent, and Primary Care Settings: A Clinical Companion (2nd ed.). New York, NY: Springer Publishing.
  7. Riviello, R. J. (2019). Otolaryngologic procedures. In J. R. Roberts et al. (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed.). Philadelphia, PA: Elsevier.
  8. Dalal PJ, Purkey MR, Price CPE, Sidle DM. Risk factors for auricular hematoma and recurrence after drainage. Laryngoscope. 2020 Mar;130(3):628-631. doi: 10.1002/lary.28310. Epub 2019 Oct 17. PMID: 31621925.
  9. 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
  10. Nahl SS, Kent SE, Curry AR. Treatment of auricular haematoma by silicone rubber splints. J Laryngol Otol 1989; 103:1146–1149
  11. Biedenbach P, Steehler KW, Anon JB. Management of auricular hematoma using aquaplast pressure dressing: operative techniques. Otolaryngol Head Neck Surg 1997;8: 114–115
  12. Giles WC, Iverson KC, King JD, et al. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007;117: 2097–2099.
  13. Jones SE, Mahendran S. Interventions for acute auricular hematoma. Cochrane Database Syst Rev 2004;(2):CD004166.
  14. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear. Facial Plast Surg. 2010 Dec;26(6):451-5. doi: 10.1055/s-0030-1267719. Epub 2010 Nov 17. PMID: 21086231.
  15. Lee D, Sperling N. Initial management of auricular trauma. Am Fam Physician 1996;53:2339–2344
  16. Vogelin E, Grobbelaar AO, Chana JS, Gault DT. Surgical correction of the cauliflower ear. Br J Plast Surg 1998;51: 359–362
  17. Yotsuyanagi T, Yamashita K, Urushidate S, Yokoi K, Sawada Y, Miyazaki S. Surgical correction of cauliflower ear. Br J Plast Surg 2002;55:380–386
  18. 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. doi: 10.1016/j.amjoto.2008.09.005. Epub 2009 Mar 26. PMID: 19944894.