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Assessment and management of auricle (ear) lacerations

Assessment and management of auricle (ear) lacerations
Literature review current through: Jan 2024.
This topic last updated: Jan 17, 2023.

INTRODUCTION — This chapter will cover assessment and management of simple and complex auricle (ear) lacerations. Once serious head or middle ear injury is excluded, careful closure of ear lacerations after copious but gentle irrigation and minimal debridement should ensure coverage of any exposed cartilage to preserve cosmetic appearance.

Minor wound management, methods of suture placement, repair of adjacent anatomic sites, and evaluation of middle ear trauma are discussed in detail separately:

(See "Minor wound evaluation and preparation for closure".)

(See "Skin laceration repair with sutures".)

(See "Assessment and management of facial lacerations".)

(See "Assessment and management of scalp lacerations".)

(See "Evaluation and management of middle ear trauma".)

ANATOMY — The external ear is composed of the auricle, or pinna, and the external auditory canal. Because of the protuberant nature of the ear, most traumatic lacerations involve the auricle; a laceration may, however, extend into the external auditory canal. The cartilaginous subunits of the auricle include: the helix, antihelix, concha, tragus, and antitragus (figure 1). These structures are composed of elastic cartilage that is continuous with the cartilaginous external auditory canal and is avascular. The cartilage receives its nutrients from the adherent perichondrium. The skin of the auricle is very thin and is densely attached to this underlying perichondrium. The earlobe is composed of fibrous adipose tissue and lacks cartilage. The function of the auricle is to amplify and direct sound to the external auditory canal, and ultimately to the tympanic membrane [1].

Cartilage exposure after auricular laceration can cause infection, erosive chondritis, and necrosis [2]. Loss of auricular cartilage (notching) or replacement of healthy cartilage with fibrocartilage ("cauliflower ear") is disfiguring and not easily reversed. Thus, ensuring tissue coverage of exposed cartilage is of paramount importance during auricular laceration repair.

In cases of auricular avulsion, knowledge of the blood supply is essential. The anterior blood supply comes from the superficial temporal artery (STA), while the posterior auricle is fed by the posterior auricular artery (PAA) (figure 2). There is a supplemental vascular supply from branches of the occipital artery [1]. The STA and PAA communicate via the helical arcade that runs along the helix; this arcade is the basis for single pedicle reimplantation of a total avulsion of the auricle [3].

The auricle is innervated by the auriculotemporal nerve superiorly and medially, the greater auricular nerve and lesser occipital nerve laterally and inferiorly, and the vagus nerve (concha and external auditory meatus).

EVALUATION — In most instances, ear lacerations result from isolated trauma. However, as for all trauma patients, the initial clinical assessment should focus on rapid identification of potentially fatal conditions. For victims of major trauma, evaluation for airway compromise (while maintaining cervical spine immobilization), impaired breathing, hemorrhagic shock, and altered level of consciousness should be performed immediately upon the patient’s arrival at the emergency department. Systematic evaluation helps ensure detection of potentially life-threatening injuries.

The approach to the injured child or adult is discussed in detail separately (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Initial management of trauma in adults".)

Auricular lacerations should be assessed during a careful and organized secondary survey. (See "Trauma management: Approach to the unstable child", section on 'Secondary survey'.)

History — The clinician should identify the following aspects of the injury:

Traumatic force (eg, a physical assault with significant likelihood of associated injuries versus an isolated injury with no other symptoms)

Associated symptoms of middle and inner ear injury (eg, tinnitus, hearing loss, vertigo, vomiting, otorrhea) (see "Evaluation and management of middle ear trauma", section on 'History')

Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

Age of wound (duration of time since the injury occurred)

Likelihood of wound contamination (eg, clean laceration from table edge with low risk of contamination versus human bite wound with high risk of bacterial contamination and need for special prophylaxis) (see 'Prophylactic antibiotics' below and 'Viral prophylaxis for bite wounds' below)

Potential presence of foreign body (eg, fall onto glass or gravel)

The history should also include a comprehensive review of underlying medical history (eg, diabetes mellitus in adults, cancer, prior keloid formation), medication use (eg, immunosuppressive agents), and social habits (eg, tobacco use) that may negatively affect healing and increase the risk for a poor outcome. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

In addition, the clinician should inquire about allergies to any medications, especially local anesthetics, and the patient’s tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and "Assessment and management of facial lacerations", section on 'Tetanus prophylaxis'.)

Physical examination — Infiltration of local anesthetics facilitates a comprehensive evaluation of the wound with minimal discomfort to the patient. In young children and other uncooperative patients, sedation may be necessary to perform optimal wound assessment and repair. (See 'Anesthesia and analgesia' below.)

Wound assessment should identify the following:

Location of the injury (eg, helix, antihelix, tragus, antitragus, concha, or earlobe (figure 1))

Depth of the injury (eg, superficial, through the perichondrium, or completely through the ear ["through and through"])

Degree of cartilage involvement

Extension of the laceration into the auditory canal

Presence of tissue avulsion

Auricular hematoma (collection of blood between the perichondrium and the cartilage) (see 'Auricular hematoma' below)

The clinician should also evaluate for the following associated injuries:

Middle ear trauma – Middle ear trauma should be suspected in patients with the following findings (see "Evaluation and management of middle ear trauma", section on 'Findings of middle ear injury'):

Hemotympanum (picture 1).

Amber or clear middle ear effusion.

Otorrhea (clear or bloody ear canal drainage).

Hearing deficit by Weber and Rinne tuning fork tests (table 2 and figure 3)

Nystagmus.

Ataxia.

Retroauricular hematoma (Battle sign) (picture 2). Battle sign typically appears two days after injury, but may appear within 6 to 12 hours.

Facial nerve (cranial nerve VII) dysfunction.

Basilar skull fracture – Hemotympanum, Battle sign, otorrhea, and facial nerve deficits are also findings of a basilar skull fracture. Affected patients may also have deficits of cranial nerves VI (abducens), and VIII (vestibulocochlear). (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture' and "Skull fractures in adults", section on 'Basilar skull fracture'.)

Facial nerve or parotid gland injury – Lacerations that extend anterior to the ear may disrupt the facial nerve and parotid gland. (See "Assessment and management of facial lacerations", section on 'Cheek'.)

Ancillary studies — Patients with clinical features suggestive of middle ear trauma or basilar skull fracture warrant the following studies:

Evaluation of any ear or nose drainage for the presence of cerebrospinal fluid (CSF) (see "Evaluation and management of middle ear trauma", section on 'Evaluation of otorrhea' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture')

Tests of hearing (see "Evaluation and management of middle ear trauma", section on 'Tests of hearing')

Temporal bone computed tomography without contrast including fine axial and coronal cuts, for patients with head trauma and/or who may require operative intervention

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Consultation with a surgical subspecialist (eg, plastic or maxillofacial surgeon, otolaryngologist, or, in patients with signs of basilar skull fracture, neurosurgeon), if available, is suggested in the following situations:

Auricular avulsion

Auricular lacerations that extend into the external auditory canal, with risk of cicatrix formation and canal stenosis

Auricular laceration with evidence of serious middle or inner ear injury such as hearing loss or vestibular symptoms (eg, nausea, vomiting, nystagmus, ataxia) (see "Evaluation and management of middle ear trauma", section on 'Indications for otolaryngology consultation or referral')

Auricular laceration with evidence of basilar skull fracture (eg, hemotympanum, cerebrospinal fluid otorrhea, Battle sign, facial nerve weakness (picture 2)) (see "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture')

Chronically split earlobe or cleft caused by wearing heavy earrings or allergy to the ear ring metal [4]

Through and through lacerations of the auricle may also be an indication for subspecialty consultation, depending upon the capability of the clinician. (See 'Complex lacerations' below.)

WOUND REPAIR

Indications for primary closure — Primary closure (ie, wound repair at the time of presentation) is the preferred treatment for auricular lacerations, especially if the ear cartilage is exposed or the wound extends through the ear. Failure to cover exposed cartilage increases the risk of infection, erosive chondritis, and/or necrosis which may lead to cartilage loss or significant cosmetic disfigurement ("cauliflower ear"). (See 'Complications' below.)

Delayed primary closure (ie, cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) may be appropriate for wounds of the earlobe that present after 24 hours and have increased risk for infection. In general, the decision should be based upon the time from injury, patient factors that increase the risk of infection (eg, vascular insufficiency, diabetes mellitus), and wound factors (bite wound, other contamination, or foreign body potential). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Contraindications and precautions — Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Auricular laceration closure should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying middle ear or intracranial injuries.

When closure is delayed, saline-soaked gauze packing (wet-dry dressing) can be provided to enhance secondary healing. Although not required based upon evidence, when prescribing antibiotics, coverage (eg, amoxicillin-clavulanate or, in penicillin allergic patients, clindamycin) should be aimed at the flora of the skin and possibly upper respiratory tract and can be initiated in selected patients with wounds other than bite wounds (eg, adult patient with diabetes mellitus, or other risks for poor wound outcome). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Indications and empiric oral antibiotic regiments for patients with animal bites (table 3) and human bites (table 4) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Preparation — Preparation for the care of auricle lacerations includes a discussion of the likely outcomes of repair, the choice of repair, assembly of the appropriate equipment, provision of anesthesia and analgesia, and wound debridement and cleansing.

General consent forms for treatment are commonly part of the registration process for all patients arriving into the emergency department (ED) and a separate written consent for wound repair in the emergency department is not usually obtained [5-7]. However, the patient and/or caregiver must be aware of the general risks of laceration repair which include infection, pain and scarring. With respect to scarring, the potential for poor cosmetic outcome after auricular laceration repair and need for further surgery should be explained to patient.

Anesthesia and analgesia

Local anesthesia — Local anesthetic infiltration using buffered lidocaine without epinephrine or similar agent (table 5) provides adequate analgesia for most simple auricular laceration repairs in adults and cooperative children. The discomfort of infiltration may be further decreased by the use of nonpharmacologic interventions such as biobehavioral and cognitive distraction. (See "Subcutaneous infiltration of local anesthetics", section on 'Procedure' and "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)

Local anesthetics that contain epinephrine should be avoided to prevent vasoconstriction and disruption of the tenuous vascular supply to the ear cartilage.

Regional auricular block — This field nerve block provides anesthesia to the auricle, with the exception of the concha and meatus, which are innervated by branches of the vagus nerve (figure 1). A regional auricular block is indicated for repair of extensive auricular lacerations or to avoid local tissue distortion when cosmetic alignment is important. It is performed as follows (figure 4) [8]:

Cleanse the ear and the surrounding skin with an antiseptic solution (eg, povidone-iodine solution).

Inject buffered lidocaine 1 percent with epinephrine using a long (1.5 inches), small gauge (25 or 27 gauge) needle. The total dose of lidocaine administered should not exceed 7 mg/kg (0.7 mL/kg) of lidocaine 1 percent.

Enter the skin at a point just below the ear and advance the needle posteriorly along the skin over the mastoid behind the ear.

Inject up to 5 mL of lidocaine (depending upon patient weight) as the needle is withdrawn.

Without removing the needle from the skin, redirect it anterior to the ear and inject up to 5 mL of lidocaine again (depending upon patient weight). The tracks should form an upright "V".

Enter the skin at a point just above the ear and advance the needle posteriorly behind the ear

Inject up to 5 mL of lidocaine (depending upon patient weight) as the needle is withdrawn

Without removing the needle from the skin, redirect it anterior to the ear and inject up to 5 mL (depending upon the patient’s weight) of lidocaine again. These tracks should form an inverted "V".

Wait approximately 10 minutes after completion of the injections in order to achieve maximum anesthesia.

Procedural sedation — Procedural sedation in children and adults is discussed in more detail separately. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Procedural sedation is likely to maximize patient comfort and cosmetic outcomes in the following situations:

Multiple complex auricular lacerations

Auricular lacerations in young children

Heavily contaminated ear lacerations that require aggressive cleaning

Highly anxious or otherwise uncooperative patients, especially when the safety of the clinician or staff may be compromised

Wound preparation — Once anesthetized, auricular lacerations should undergo copious irrigation with 100 to 200 mL of sterile normal saline. During irrigation, the clinician should avoid excessive irrigation pressure that might strip the perichondrium from the cartilage. Wound irrigation is discussed in greater detail separately. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation'.)

Debridement of skin should be avoided or kept to a minimum to ensure that any exposed cartilage can be covered. Cartilage should not be débrided so as to avoid notching of the auricular contours.

Equipment — The following equipment should be assembled for auricular laceration repair:

Sterile gloves

Surgical mask

Eye protection

Buffered 1 percent lidocaine or similar local anesthetic (table 5)

Moderate volume syringe (eg, 5 or 10 mL)

Small gauge needle (eg, 27 or 30 gauge, 1.5 inch if performing an auricular block) for infiltration of local anesthetic

Suture material:

For skin, 5-0 or 6.0 nonabsorbable sutures (eg, nylon [Ethilon], polybutester [Novafil], polypropylene [Prolene] (table 6)). In children 6.0 absorbable sutures (eg, fast-absorbing gut) avoids the trauma of suture removal and may be preferable.

For perichondrium, undyed 5.0 absorbable sutures (eg, poliglecaprone 25 [Monocryl], polyglactin [Vicryl], polyglycolic acid [Dexon] (table 7)).

Needle holder

Hemostat

Scalpel with handle (#15 blade) if debridement or revision are planned

Tissue forceps

Scissors

Sterile 4 x 4 gauze

Absorbent towels

Sterile field drapes

Emergency departments generally are well equipped with minor surgical or suture trays that contain the instruments, sterile gauze, towels, and drapes listed above.

Techniques — Auricular lacerations can be described as simple, complex, or avulsion injuries [9]. The type of injury largely determines the surgical approach. The clinician should also be alert for signs of an auricular hematoma, which must be drained to prevent pressure necrosis of the ear cartilage. (See 'Auricular hematoma' below.)

Regardless of the nature of the injury, the patient’s contralateral ear serves as an excellent model when normal landmarks are obscured.

Simple lacerations — Simple lacerations that spare cartilage most commonly involve the earlobe but may also involve other parts of the auricle. These wounds can be closed with simple interrupted sutures using 6.0 nonabsorbable sutures (table 6) or, in young children and patients without assured follow-up, 6.0 absorbable suture, such as fast-absorbing gut. When nonabsorbable suture is used, some experts prefer monofilament polybutester (Novafil) because of its greater elasticity and decreased potential for suture marks. (See "Skin laceration repair with sutures", section on 'Percutaneous closure' and "Skin laceration repair with sutures", section on 'Suture selection'.)

Split earlobe — Split earlobes are most commonly caused by pulling through of earrings or allergy to earring metal alloys. Acute wounds require subcutaneous placement of 4.0 or 5.0 absorbable suture (eg, poliglecaprone 25 [Monocryl] or polyglycolic acid [Dexon] (table 7)) and skin closure of the front and the back of the earlobe with 6.0 nonabsorbable sutures (eg, polybutester [Novafil]) or, in young children and patients without assured follow-up, 6.0 absorbable sutures (fast-absorbing gut). Careful approximation is important.

Clinicians with less experience managing these injuries may wish to refer them to an appropriate surgical specialist, when available, because primary closure of these earlobe lacerations can be complicated by notching and recurrence of the cleft. Thus, multiple cosmetic techniques based upon the classic Z-plasty have been developed [10,11]. Some surgeons will close the laceration around an angiocatheter or other stenting device to preserve a piercing for future earring use; a less complicated approach closes the entire laceration and allows for re-piercing as early as six weeks following repair [9].

When the split earlobe is chronic and epithelialized, the wound management is complicated by the need to excise skin margins of the cleft and to provide repair that avoids loss of earlobe tissue strength and prevents recurrence [12]. Various techniques, including straight repair, Z-plasty, flap method, or concha cartilage graft have been proposed and are best performed by an appropriate surgical specialist [10,12].

Complex lacerations — Auricular lacerations that expose or extend through the cartilage require careful closure. The perichondrium must be reapproximated and the cartilage covered with skin in order to prevent notching or a step-deformity [8,13]. Because the overlying skin is so thin and is so densely adherent to the underlying perichondrium, stitches that incorporate both layers are appropriate; burying perichondrial sutures under such thin auricular skin is technically challenging and can produce unwanted subcutaneous nodularity. Furthermore, any absorbable suture utilized, particularly for buried sutures, should be undyed in order to avoid tattooing. Generally speaking, suture should not be passed through the cartilage itself. The perichondrial sutures should be the deepest layer of closure.

As with simple ear lacerations, nonabsorbable monofilament 6.0 suture (eg, polybutester [Novafil]) (table 6) should be used and is appropriate if the patient can follow-up for removal in 7 to 10 days. In young children and those patients with uncertain follow-up, 6.0 fast-absorbing gut may be used.

Avulsion injuries — Avulsion injuries of the ear usually warrant subspecialty consultation for definitive repair. Avulsion injuries are designated as follows [9]:

Partial avulsion with a wide pedicle – As long as capillary refill distal to the avulsion is adequate, these wounds respond well to primary closure as for complex lacerations described above. (See 'Complex lacerations' above.)

Wounds that extend into the auditory canal require meticulous approximation and, in some instances, grafting to achieve adequate closure [9]. Placement of an ear wick can help prevent the formation of canal stenosis or cicatrix. Repair by a surgical subspecialist, if available, is advised.

Partial avulsion with a narrow pedicle – These wounds can have marginal blood supply to the avulsed segment. Surgical methods to preserve the segment such as local advancement flaps may be necessary and are best performed by an experienced surgical subspecialist [14].

Complete avulsion – Management of complete avulsion of the auricle depends upon the availability and integrity of the avulsed segment:

If the avulsed segment is absent, local wound care should be provided and subspecialty consultation obtained. The missing auricle can be reconstructed in an immediate or delayed fashion, depending upon the judgment of the subspecialty consultant. Exposed cartilage may be best treated with local advancement flaps to preserve remaining structure where possible.

Any completely avulsed segment that is available should be wrapped in gauze and placed in a sterile plastic bag, then submerged in a 4°C ice bath until subspecialty consultation is available [9]. Repair ideally occurs immediately (ie, within four hours of the injury); however, reimplantation has been reported to be successful up to 33 hours after the avulsion [15]. Ultimately, the decision to reimplant depends upon whether vessels suitable for microvascular anastomosis are present in the avulsed segment [9,14,16]. Clinicians should exercise caution regarding the use of pressure dressings to the ear.

OTHER CONSIDERATIONS

Tetanus prophylaxis — Tetanus prophylaxis should be provided for all wounds as indicated (table 8). Pregnant women should receive immunization based upon their immunization history, as discussed in detail separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Prophylactic antibiotics — Most ear wounds do not warrant empiric antibiotic treatment. Prophylactic antibiotics may decrease the risk of wound infection in patients with animal or human bites, excessive wound contamination, vascular insufficiency (eg, peripheral artery disease), degloved/exposed cartilage, or immunodeficiency. The evidence for the use of prophylactic antibiotics after the closure of skin wounds other than bite wounds is discussed separately. (See "Skin laceration repair with sutures", section on 'Prophylactic antibiotics'.)

For a laceration that involves cartilage, we do not routinely use prophylactic antibiotics [17]. There is insufficient evidence on the use of antibiotics to prevent chondritis. Some experts use antibiotics (eg, ciprofloxacin) for all penetrating auricular injuries that involve cartilage [18]. Other experts use prophylactic antibiotics only in the setting of grossly contaminated, degloved, or exposed cartilage or when cartilage itself needs to be repaired [17,19]. We agree with the latter approach.

Indications for antibiotics and empiric oral antibiotic regimens for patients with animal bites (table 3) and human bites (table 4) are discussed separately. When the ear cartilage is exposed after a bite wound, some experts will administer 24 to 48 hours of intravenous antibiotics followed by delayed primary closure [20]. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Viral prophylaxis for bite wounds — Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin can all transmit rabies. Early wound cleansing is an important prophylactic measure, in addition to timely administration of rabies immune globulin and vaccine (table 9). Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis" and "Rabies immune globulin and vaccine".)

In general, the risk of contracting HIV, hepatitis B, or hepatitis C from a human bite is negligible unless blood exposure has also occurred. If the biter has been exposed to blood from an infected bite victim, then prophylaxis may be appropriate as discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)

AFTERCARE — Postoperative care for ear lacerations closed with nonabsorbable sutures includes the following:

Daily gentle cleansing of the incision followed by topical application of triple antibiotic ointment (eg, Polysporin) to the wound.

Although ear pressure dressings are used by some clinicians to reduce the risk for the development (or recurrence) of an auricular hematoma [8,13], the authors typically avoid such bandages after simple auricular laceration repair because auricular hematomas are uncommon with such wounds and wound compression may cause vascular compromise and poor healing.

Patients should be reevaluated in 24 to 48 hours to assess for signs of infection or auricular hematoma. (See 'Perichondritis or chondritis' below and 'Auricular hematoma' below.)

Nonabsorbable sutures should be removed in 7 to 10 days. The wound should not be submerged in water until the skin edges have completely healed.

COMPLICATIONS — Complications after auricular repair include notching of the auricle, auricular hematoma with the formation of a "cauliflower ear", scarring, perichondritis, and chondritis. Patients with split earlobes may experience recurrence of earlobe notching or splitting, especially if they continue to wear heavy earrings.

Auricular notching — Notching of the auricle is due to loss of auricular cartilage and may occur even after an optimal repair. Potential causes include:

Poor skin or cartilage alignment during wound repair.

Cartilage damage during wound debridement or repair.

Vascular insufficiency after auricular avulsion repair. Necrosis and failure of the reconstruction may occur despite best efforts by the surgical subspecialist.

Local wound infection with perichondritis or chondritis.

Auricular hematoma — Although most commonly occurring after blunt trauma during sports (eg, amateur wrestling, rugby, boxing), auricular hematomas may occur after wound closure. This complication warrants prompt drainage and application of a pressure dressing to prevent reaccumulation of blood. Fibrocartilage overgrowth, or "cauliflower ear" can occur if drainage is incomplete or if the hematoma recurs. The assessment and management of auricular hematoma and cauliflower ear are discussed separately. (See "Assessment and management of auricular hematoma and cauliflower ear".)

Perichondritis or chondritis — Perichondritis arises from infection of the perichondrium. Chondritis is inflammation and infection of the cartilage itself. These infections can result in drastic deformity of the ear (picture 3) [21]. Signs of perichondritis or chondritis include pain, swelling and erythema of the overlying skin. Fluctuant swelling indicates an abscess that must be drained; Pseudomonas aeruginosa is the pathogen in up to 95 percent of cases [22]. Antibiotic options include oral fluoroquinolones (eg, levofloxacin) in adolescents and adults and parenteral antibiotics (eg, ceftazidime) in children. Even with timely and proper antibiotic treatment, these infections may result in cartilage necrosis and cosmetic disfigurement.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Stitches and staples (The Basics)")

SUMMARY AND RECOMMENDATIONS

Anatomy – The external ear is composed of the auricle, or pinna, and the external auditory canal. Because of the protuberant nature of the ear, most traumatic lacerations involve the auricle. The cartilaginous subunits of the auricle include: the helix, antihelix, concha, tragus, and antitragus (figure 1). (See 'Anatomy' above.)

Evaluation – Patients with auricular (ear) lacerations require careful evaluation to determine the location and depth of the injury, degree of cartilage involvement, extension of the laceration into the auditory canal, and the presence of tissue avulsion. In addition, patients with major trauma should be assessed for signs of associated middle ear injury and basilar skull fracture. (See 'Evaluation' above.)

Specialty consultation – Patients with auricular avulsions, external ear lacerations that extend into the external auditory canal, chronically split earlobes or clefts, or have associated middle ear trauma or basilar skull fractures warrant consultation with an appropriate surgical subspecialist. Through and through lacerations of the auricle may also be an indication for subspecialty consultation, depending upon the capability of the clinician. (See 'Indications for subspecialty consultation or referral' above.)

Indications for closure – Primary closure (ie, wound repair at the time of presentation) is the preferred treatment for auricular lacerations, especially if the ear cartilage is exposed or the wound extends through the ear. Failure to cover exposed cartilage increases the risk of infection, erosive chondritis, and/or necrosis with resulting cartilage loss or significant cosmetic disfigurement ("cauliflower ear"). (See 'Indications for primary closure' above.)

Contraindications for closure – Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Auricular laceration closure should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying middle ear or intracranial injuries. (See 'Contraindications and precautions' above.)

Preparation – Infiltration of local anesthesia (eg, lidocaine 1 percent without epinephrine) or a regional auricular nerve block (figure 4) typically provides adequate analgesia for closure of auricular lacerations. (See 'Anesthesia and analgesia' above.)

Once anesthetized, auricular lacerations should undergo copious irrigation with 100 to 200 mL of sterile normal saline. During irrigation, the clinician should avoid excessive irrigation pressure that might strip the perichondrium from the cartilage. Debridement of skin should be avoided or kept to a minimum to ensure that any exposed cartilage can be covered. Cartilage should not be debrided so as to avoid notching of the auricular contours. (See 'Wound preparation' above.)

Techniques for closure – The suggested equipment and techniques for closure of auricular lacerations according to wound type are provided above. (See 'Equipment' above and 'Techniques' above.)

Additional management – All patients should receive tetanus prophylaxis, as needed. Most ear wounds do not warrant empiric antibiotic treatment. However, prophylactic antibiotics may decrease the risk of wound infection or chondritis in patients with animal or human bites, excessive wound contamination, vascular insufficiency (eg, peripheral artery disease), degloved/exposed cartilage, cartilage that requires repair, or immunodeficiency. (See 'Other considerations' above.)

Aftercare – Repaired auricular lacerations warrant close follow-up in 24 hours to assess for signs of infection or auricular hematoma. Nonabsorbable sutures should be removed 7 to 10 days after repair. (See 'Aftercare' above.)

Complications – Auricular hematomas, perichondritis, and chondritis are potential complications of auricular lacerations that warrant prompt recognition and treatment during follow-up. (See 'Auricular hematoma' above and 'Perichondritis or chondritis' above.)

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Topic 13874 Version 20.0

References

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