Auricular hematoma describes a collection of blood within the cartilaginous auricle (outer ear) which typically results from blunt trauma during sports (eg, amateur wrestling, rugby, boxing, or mixed martial arts). This injury warrants prompt drainage and measures to prevent reaccumulation of blood. An auricular hematoma is an injury to the outer ear. This injury can occur when the outer ear is either hit directly or receives repetitive blows. It is more common in wrestling, rugby, boxing, and mixed martial arts. This injury can cause blood to collect under the skin of the ear next to the cartilage. An auricular hematoma is typically diagnosed after a detailed history and physical. Ultrasound can be utilized to evaluate ear swelling and to rule out an auricular abscess.
Auricular hematomas are treated by either needle aspiration or incision and drainage. Both techniques should be performed under sterile conditions after adequate analgesia with either a regional auricular block or local infiltration.
An auricular hematoma is a collection of blood underneath the perichondrium of the ear and typically occurs secondary to trauma.[1] Auricular deformity, commonly known as “cauliflower ear” is the result of untreated or inadequately treated auricular hematoma. It is important to recognize and drain this collection since a persistent hematoma can induce cartilage destruction with subsequent deformity of the ear.
Causes
Auricular hematoma is typically caused by trauma. This can be from multiple forms of trauma, such as earring placement though is more common with a larger force or direct blow to the ear such as from a motor vehicle accident. It is most commonly secondary to contact sports such as wrestling, boxing, and martial arts.
- Caused by a 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”)
- Failure to wear headgear while participating in sports can cause ear trauma
- Auricular Hematoma<
- Ear Laceration
- Cellulitis
- Perichondritis
Diagnosis
- Hematoma of Auricle on physical exam
- Tenderness over hematoma
- Asymmetry compared to the opposite auricle
- 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 the ear
- Assess for signs and symptoms of concussion
Histologic changes account for the altered appearance of the external ear noted after an auricular hematoma. The cartilage of the ear is usually composed of elastic cartilage. Secondary to trauma, the normal cartilage structure of the ear changes. Two weeks after the auricular hematoma develops, cartilage formation occurs on either side of the hematoma. After three weeks, the hematoma is replaced by soft tissue. By eight weeks post-trauma, the soft tissue is replaced by cartilage. By fourteen weeks, bony formation, calcification, and further cartilage growth occur.[7]
History and Physical
Always start with open-ended questions and standard history. Specific questions which are important to ask are recent trauma, pain/tenderness of the ear, previous occurrences, fevers/chills, drainage from ears, change in hearing, immunosuppression, diabetes, blood-thinning medications, and hypertension. A physical exam involves a thorough evaluation of the external ear. It is important to have a good understanding of the baseline anatomy of the ear to better differentiate pathology. The use of an otoscope to evaluate the external ear canal and tympanic membrane is paramount. A recent history of trauma is common, and wrestling and boxing are common risk factors. If the mechanism of trauma is large, such as a motor vehicle accident, the practitioner must rule out temporal bone trauma as well as assess the patient for other injuries.
A proper exam includes a full head and neck exam, the details of which are beyond the scope of this article. 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 the ear with swelling and fluctuant area overlying the ear’s cartilaginous portions. Likely symptoms include pain, paresthesia, and ecchymosis.[8]
An auricular hematoma is typically diagnosed after a detailed history and physical. Ultrasound can be utilized to evaluate ear swelling and to rule out an auricular abscess. If significant trauma has occurred, there is a concern for a foreign body or an abscess or it is determined that it is important to evaluate middle or inner ear structures, CT or MRI can be ordered. CT and MRI should not be used routinely to evaluate auricular hematomas.
If there is evidence of erythema, warmth to the area, diffuse pain on palpation of cartilage, evidence of external auditory canal swelling, or drainage, then the diagnosis of auricular hematoma is less likely. Typically, hearing is not affected by isolated auricular trauma and if the patient has subjective hearing loss, then expanding the differential diagnosis is warranted. In summary, auricular hematomas are generally a clinical diagnosis.
Treatment
- Provide local anesthesia with lidocaine without epinephrine
- Aspirate with 18 to 22 gauge needle
- Apply compression dressing to avoid reaccumulation of hematoma (keep in place until healed)
- Consider preventive antibiotics covering gram-positive skin bacteria (Cephalexin x 7 days)
- Avoid NSAIDs and Aspirin to minimize hematoma recurrence
Once a hematoma is diagnosed the next step is determining whether treatment should occur in the operating room or at the bedside. It is important to discuss with the patient the risks, benefits, and alternatives to treatment. If the hematoma occurred in an acute setting < 48 hours, an attempt at drainage is appropriate. Keep in mind that patients can opt for no treatment which is acceptable as long as the patient knows the risks and possible poor cosmetic outcomes of nontreatment.
General Procedure Steps for Auricular Hematoma Drainage:
- 1) Gather the necessary equipment and make sure there is appropriate lighting.
- 2) Ensure adequate exposure and place the patient in the supine position with the head of the bed elevated.
- 3) The patient’s head should be turned so that the unaffected ear is facing toward the stretcher and the affected ear is towards the ceiling.
- 4) Supplies should consist of an 11 blade or 15 blade scalpel and/or an 18-gauge needle with a 10 cc syringe, suction canister, tubing and suctioning instrument (Frasier), a hemostat, toothed forceps, suture supplies with scissors, bolster material, local anesthetic, and local skin cleansing material.[1]
- 5) Appropriate hand hygiene should be practiced and gloves should be worn during the procedure. Application of sterile gloves, gowning, headlamp use, and or Loupes to optimize vision are optional.
- 6) After the patient is positioned properly, the ear is cleaned with a local cleansing agent such as povidone-iodine.
- 7) Local anesthesia should then be injected or applied topically to the site where the incision or aspiration will be performed (e.g., lidocaine, bupivacaine, LET gel). For best results, the anesthetic can be injected in an auricular block pattern or directly into the site of the auricular hematoma. Several minutes after injection the level of local anesthesia should be assessed. This can be performed by grabbing the tissue of the planned incision with toothed forceps to determine if the area is numb. There are two methods that can potentially be used to drain the auricular hematoma. You should choose the method you will utilize prior to starting of the procedure. One method is to incise and drain the hematoma using a scalpel the other is needle aspiration
Incision and drainage:
- I. First complete steps 1 through 7 listed above under general procedure steps.
- II. Next make a linear incision can be made on the skin overlying the swelling or hematoma.[1] The goal of the incision is to drain the fluid collection; however, making the incision in a cosmetically appealing site is ideal. The incision in areas of concavity will heal with more aesthetically pleasing results compared to areas of convexity.
- III. After the incision is made, hemostats and suction can be used to evacuate the hematoma.
- IV. Once all the hematoma is removed, the site can be irrigated with normal saline.
- V. A bolster dressing is applied. The bolster serves to close the dead space or potential space where the hematoma formed. When using dental rolls as a bolster, two rolls should be used. Each roll should be placed so it to runs parallel with the incision line on either side of the ear. Two vertical mattress sutures should be placed through the dental rolls to secure the bolster.[1] A permanent suture material such as nylon is appropriate. The suture is ideally on a Keith Needle; however, this is not mandatory. The adequate bolster is applied when there is no potential space for accumulation of hematoma; however, it is important to make the sutures lose enough to preserve the vascular supply of the ear.
- VI. Bacitracin can be applied to the incision site post-procedure.
- VII. It is important to remove all instruments and dispose of sharps appropriately once the procedure is deemed complete. Proper wound care instructions, follow-up, and disposition should be explained to the patient and/or family.
Needle Aspiration:
- I. First complete steps 1 through 7 listed above under general procedure steps.
- II. The alternate procedure utilizes an 18-gauge needle to aspirate the hematoma. Some studies suggest that an 18-gauge needle may be acceptable for auricular hematoma evacuation when the hematoma is under 2 cm.[1] If the needle aspiration technique is used a bolster should be applied to the affected area of the ear after complete removal of the hematoma.
- III. A bolster dressing is applied. The bolster serves to close the dead space or potential space where the hematoma formed. When using dental rolls as a bolster, two rolls should be used. Each roll should be placed so it runs parallel with the incision line on either side of the ear. Two vertical mattress sutures should be placed through the dental rolls to secure the bolster.[1] A permanent suture material such as nylon is appropriate. The suture is ideally on a Keith Needle; however, this is not mandatory. The adequate bolster is applied when there is no potential space for accumulation of hematoma; however, it is important to make the sutures lose enough to preserve the vascular supply of the ear.
- IV. Bacitracin can be applied to the incision site post-procedure.
- V. It is important to remove all instruments and dispose of sharps appropriately once the procedure is deemed complete. Proper wound care instructions, follow-up, and disposition should be explained to the patient and/or family.
Bolster Options Post Hematoma Evacuation:
- There are several variances in the type of bolster used, however, the goal is the same: eliminate the potential space for fluid to accumulate.[1] Newer strategies include the use of splinting material that can be molded to the ear.[2] A recent case reports using fibrin glue to secure the perichondrium to the cartilage to reduce the risk of separation.[3] Bolster dressing can be removed after 5 to 7 days. Antibiotic use is left to the discretion of the physician. If cauliflower ear does form, excision with repair may be undertaken in the form of otoplasty; however, this will require referral to ENT or plastic surgery.[1]
