Version May 2024
INTRODUCTION — This topic reviews the assessment and management of auricular hematoma focusing on an approach that best avoids the long-term complication of cauliflower ear. The assessment and management of auricle (ear) lacerations is discussed separately. (See "Assessment and management of auricle (ear) lacerations".)
DEFINITIONS — 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.
Cauliflower ear is the permanent deformity caused by fibrocartilage overgrowth that occurs when an auricular hematoma is not fully drained, recurs, or is left untreated (picture 1).
ANATOMY AND PATHOPHYSIOLOGY — The uniquely protuberant nature of the external ear makes it particularly susceptible to trauma. The cartilaginous subunits of the pinna include the helix, the antihelix, the concha, tragus, and antitragus (figure 1) [1]. The lobule, or ear lobe, is composed of fibroadipose tissue and lacks cartilage. The skin overlying the cartilaginous auricle, or pinna, is thin, without significant subcutaneous adipose tissue, and is densely adherent to the underlying perichondrium. The perichondrium, in turn, supplies nutrients to the auricular cartilage.
When traumatic hematoma occurs, the blood accumulates within the subperichondrial space (between the perichondrium and cartilage). This collection of blood is a mechanical barrier between the cartilage and its perichondrial blood supply [1]. Deprived of perfusion, the underlying cartilage necroses and may become infected. These pathologic changes result in cartilage loss followed by fibrosis and neocartilage formation. This healing process is disorganized and results in the cosmetic deformity of cauliflower ear (picture 1). Early drainage of the hematoma and re-apposition of the perichondrial layer to the underlying cartilage restores perfusion to the cartilage and reduces the likelihood of cauliflower ear.
MECHANISM OF INJURY — Auricular hematoma and cauliflower ear are common sports injuries that occur after a direct blow or blows to the ear. While epidemiologic data are lacking, rugby, boxing, wrestling, and mixed martial arts or "ultimate fighting" are the sports typically associated with these injuries. Fighters who do not wear protective head gear are at greater risk. As an example, in a survey of collegiate wrestlers, auricular injuries occurred more frequently among wrestlers who were not wearing headgear (52 versus 26 percent for auricular hematoma and 27 versus 11 percent for cauliflower ear, respectively) [2]. Fighters with auricular hematoma also tend to ignore the injury and, even if treated, risk recurrent injury with ultimate development of cauliflower ear [3].
CLINICAL FEATURES AND DIAGNOSIS — The diagnosis of auricular hematoma or cauliflower ear is made by the characteristic clinical appearance in patients with a history of blunt trauma to the auricle.
Acute auricular hematoma presents as a tender, tense, fluctuant collection of blood, typically on the anterior aspect of the pinna and often within the scaphoid fossa, the depression between the helix and antihelix (figure 1). The overlying skin can be erythematous or ecchymotic. If the hematoma has begun to clot and organize (approximately 24 hours after injury), it may become firmer.
By contrast, cauliflower ear is a chronic, bulbous deformity of the pinna in the area of a former auricular hematoma (picture 1).
Most auricular hematomas result from an isolated blow to the ear during sports and have few associated injuries. Less commonly, auricular hematomas may accompany serious injury to the head, ear drum, or middle ear during motor vehicle collisions or other high energy mechanisms. The assessment and management of these injuries are discussed separately.
●(See "Assessment and management of auricle (ear) lacerations", section on 'Evaluation'.)
●(See "Evaluation and management of middle ear trauma", section on 'Evaluation'.)
●(See "Acute mild traumatic brain injury (concussion) in adults", section on 'Clinical features'.)
DIFFERENTIAL DIAGNOSIS — In most patients, the diagnosis of auricular hematoma or cauliflower ear is straightforward. Infections of the ear cartilage or inflammation from relapsing polychondritis may occasionally mimic these injuries.
Perichondritis, chondritis, or auricular abscess present with pain, swelling, and erythema of the overlying skin. Fluctuant swelling indicates an abscess. These infections typically accompany a recent helical ear piercing or laceration but have physical findings that may be difficult to differentiate from an auricular hematoma in some patients. The presence of pus rather than blood at the time of drainage indicates an auricular abscess. A prior break in the skin followed by erythema often identifies perichondritis or chondritis. Further therapy includes antibiotic treatment which is discussed separately. (See "Assessment and management of auricle (ear) lacerations", section on 'Perichondritis or chondritis'.)
Relapsing polychondritis (RPC) is an uncommon autoimmune condition in adults that can mimic traumatic cauliflower ear (picture 2 and picture 3). Auricular involvement is the most frequent feature of RPC, but other anatomic areas and organs may be involved, including the costal cartilage, eyes, nose, airways, heart, vascular system, skin, joints, kidney, and nervous system (table 1). Involvement of other anatomic areas or organs and the presence of nonspecific constitutional symptoms such as fatigue, malaise, and fever help to distinguish RPC from cauliflower ear. (See "Clinical manifestations of relapsing polychondritis", section on 'Clinical manifestations'.)
INDICATIONS FOR TREATMENT AND SUBSPECIALTY CONSULTATION OR REFERRAL — All auricular hematomas should be drained as soon as possible after injury. Hematomas greater than seven days old may have begun to organize and form granulation tissue and warrant referral to an otolaryngologist or plastic surgeon [4,5].
Most auricular hematomas occur in healthy young athletes. However, anticoagulated patients may develop auricular hematomas after incidental trauma. The approach to these patients depends upon the indication for anticoagulation, the individual risk of thromboembolism if anticoagulation is interrupted, and the type of anticoagulant the patient is receiving. In some cases, referral to an otolaryngologist or plastic surgeon for delayed drainage after anticoagulation is reduced or interrupted may be necessary. Consultation with a hematologist is advised to guide management of anticoagulation before and after hematoma drainage. (See "Perioperative management of patients receiving anticoagulants", section on 'Overview of our approach'.)
PREPARATION
Evaluation and patient counseling — The patient's ear should be examined both visually and by palpation to determine the location and extent of the hematoma. Physical findings determine the type of drainage (needle aspiration versus incision and drainage) and the surgical approach. (See 'Approach' below.)
The patient or caregiver should be informed regarding the need for drainage to reduce, but not eliminate the chances of cauliflower ear, and the need for appropriate follow-up. They should also be counseled regarding the need to avoid reinjury to the ear while it is healing; this is important in the case of athletes who are anxious to return to training. The clinician should emphasize that re-accumulation of blood will result in a poor cosmetic outcome. (See 'Return to sports' below.)
Additional risks that should be reviewed during the informed consent process include bleeding, infection, pain, scar formation, and need for further surgery. For anticoagulated patients, consultation with a hematologist is advised to guide management of anticoagulation before and after hematoma drainage. (See "Perioperative management of patients receiving anticoagulants", section on 'Overview of our approach'.)
Analgesia — A regional auricular block using a local anesthetic, such as 1 or 2 percent buffered lidocaine with epinephrine usually provides adequate anesthesia for drainage of an auricular hematoma in the cooperative patient. Of note, lidocaine with epinephrine is helpful for regional blocks but is generally avoided in direct infiltration of the ear itself as the vasoconstrictive properties of epinephrine can compromise the auricular blood supply. The discomfort of infiltration may be further decreased by the use of nonpharmacologic interventions such as biobehavioral and cognitive distraction. (See "Assessment and management of auricle (ear) lacerations", section on 'Local anesthesia' and "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)
The technique for performing a regional auricular block is discussed in detail separately (figure 2). (See "Assessment and management of auricle (ear) lacerations", section on 'Regional auricular block'.)
Procedural sedation is infrequently required for drainage of auricular hematoma, unless the patient is young or otherwise uncooperative. The performance of procedural sedation in children and adults is discussed in more detail elsewhere. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
Equipment — The following equipment should be assembled for auricular hematoma incision and drainage:
●Sterile gloves
●Surgical mask
●Eye protection
●Buffered 1 percent lidocaine or similar local anesthetic (table 2)
●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
●Sterile saline
●18 gauge needle attached to a small to moderate volume syringe (eg, 3 to 6 mL) if needle aspiration is performed
●18 gauge intravenous catheter if needle aspiration with indwelling catheter technique is used
●Suture material: for skin- 5-0 absorbable (eg, Monocryl or fast absorbing gut), for bolster, 4-0 or 3-0 non-absorbable (eg, nylon or Prolene)
●Needle holder
●Hemostat
●Scalpel with handle (#15 blade or #11 blade)
●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.
PROCEDURE
Approach — Evidence for the best treatment of auricular hematomas is limited and based largely upon case reports and anecdotal experience [6]. Our approach depends upon the size and age of the auricular hematoma [1,4,7,8]. Auricular hematomas that are more than seven days old warrant referral to a surgical subspecialist for debridement of new perichondrial growth and any remaining hematoma [4]. (See 'Indications for treatment and subspecialty consultation or referral' above.)
We suggest that patients with auricular hematomas that are <2 cm in diameter and present for up to 48 hours undergo needle aspiration rather than either incision and drainage, or evacuation using an intravascular catheter [4,7]. (See 'Small, acute auricular hematomas' below.)
We suggest that patients with auricular hematomas ≥2 cm in diameter and all hematomas present from 48 hours up to seven days receive either incision and drainage or evacuation using an intravascular catheter rather than needle aspiration [1,4,7,8]. (See 'Larger auricular hematomas' below.)
Some experts favor incision and drainage over needle aspiration for all auricular hematomas to avoid recurrent hematoma and its sequelae. In one small observational study of 22 patients undergoing 28 treatments, hematoma reaccumulation occurred in three out of seven patients after needle aspiration (18 to 22 gauge needles were used) versus 2 out of 21 patients undergoing incision and drainage, although this difference was not statistically significant [9]. However, outcomes were not controlled for age and size of the hematomas. Our experience suggests that needle aspiration of small, acute auricular hematomas is frequently successful.
In another series of 53 wrestlers with auricular hematoma at least 2 cm in size and present for up to three weeks, reaccumulation was seen in only three patients after evacuation with an indwelling 18 gauge intravenous catheter; the catheter had fallen out in all of these patients during the first three days after treatment [8]. This technique permitted return to sports within seven days in 91 percent of patients. Cauliflower ear developed in one athlete who did not use headgear.
Thus, limited observational evidence suggests that either incision and drainage or evacuation with an indwelling intravenous catheter effectively treats large auricular hematomas (≥2 cm) with similar rates of reaccumulation or development of cauliflower ear.
Small, acute auricular hematomas — The clinician may perform needle aspiration for small (less than approximately 2 cm in diameter) and acute hematomas that are 24 to 48 hours old as follows [4,7] (see 'Approach' above):
●Cleanse the ear with antiseptic (eg, povidone-iodine solution).
●Provide local anesthesia (figure 2). (See "Assessment and management of auricle (ear) lacerations", section on 'Local anesthesia' and "Assessment and management of auricle (ear) lacerations", section on 'Regional auricular block'.)
●Identify and aspirate the most fluctuant part of the hematoma with an 18 gauge needle while milking the hematoma to ensure complete drainage (figure 3).
●After needle aspiration, apply pressure for 5 to 10 minutes and then place a pressure dressing as follows (figure 4):
•Place sterile gauze with the center cut out to provide padding behind the ear.
•Mold sterile petrolatum-impregnated gauze or saline-soaked cotton balls within the contours of the auricle. If the skin was incised, this portion of the dressing needs to reapproximate the skin at the incision site.
•Place sterile gauze over the entire ear.
•Wrap the ear and head with sterile rolled gauze to hold in place.
Larger auricular hematomas — For larger (≥2 cm) hematomas up to seven days old, the clinician may perform incision and drainage or evacuation with an intravenous catheter [1,4,7,8]:
Incision and drainage — Incision and drainage is performed as follows [1,4,7]:
●Cleanse the ear with antiseptic (eg, povidone-iodine solution).
●Provide local anesthesia (figure 2). (See "Assessment and management of auricle (ear) lacerations", section on 'Local anesthesia' and "Assessment and management of auricle (ear) lacerations", section on 'Regional auricular block'.)
●Incise along the curvature of the auricle at the base of the hematoma using a 15 or 11 blade (figure 3). The incision should be adequate to drain clotted blood completely and is best performed parallel to the helical curve for cosmesis (figure 1).
●Carefully evacuate the hematoma and any clots by gently using a sterile mosquito hemostat to bluntly open the hematoma pocket without damaging the perichondrium.
●Irrigate the pocket copiously with sterile saline.
●After incision and drainage is performed, suture the incision closed with mattress stitches or a bolster to effectively reduce the dead space and to prevent reaccumulation of blood or fluid. Either method restores the relationship of the cartilage with its blood supply from the overlying perichondrium [1,3,6,9,10]:
•If mattress sutures are used, appose the skin and perichondrial flap to the underlying cartilage using absorbable (eg, 5-0 Monocryl or fast absorbing gut) or nonabsorbable suture (eg, 5-0 nylon or Prolene) and place the mattress stitch through and through the cartilage (figure 5) [3,10]. Leave a small area open to drain.
•If a bolster is used, we typically use sterile petrolatum-impregnated gauze which is molded to the ear and sutured into place with through and through nonabsorbable suture (eg, 3-0 or 4-0 nylon or Prolene) [1,3,6,9,11]. Alternatively, the bolster can be molded from thermoplastic splinting material and sutured into place (figure 6). Bolsters are typically removed at seven days.
Placement of fibrin glue (eg, Evicel or Tisseel) in the hematoma cavity after irrigation has been described in a case series of five patients who presented with recurrent or delayed auricular hematomas [12]. All patients had complete resolution of the hematoma with good cosmetic outcomes three months after the injury.
Intravenous catheter evacuation — The following steps describe evacuation of an auricular hematoma with an intravenous catheter (picture 4) [8]:
●Cleanse the ear with antiseptic (eg, povidone-iodine solution).
●Provide local anesthesia (figure 2). (See "Assessment and management of auricle (ear) lacerations", section on 'Local anesthesia' and "Assessment and management of auricle (ear) lacerations", section on 'Regional auricular block'.)
●Along the inferior border of the hematoma, insert an 18 gauge intravenous catheter, attach a syringe, and evacuate it as described above for needle aspiration [8]. (See 'Small, acute auricular hematomas' above.)
●Remove the needle but leave the catheter in position.
●Clip the catheter so that approximately 1 cm protrudes from the insertion site to allow further drainage.
●Dress as for needle aspiration as previously discussed and then apply a three inch elastic bandage over the gauze bandage. (See 'Small, acute auricular hematomas' above.)
AFTERCARE — Patients who have undergone evacuation of an auricular hematoma should be reevaluated every 24 hours for three to five days to evaluate for possible reaccumulation of the hematoma or signs of infection and, if evacuation with an indwelling catheter is performed, reapplication of the pressure dressing. In patients who do have recurrence of an auricular hematoma, repeated incision and drainage or catheter aspiration can be performed [8,11]. Placement of fibrin glue in the hematoma cavity was associated with good cosmetic outcomes and no further reaccumulation in two patients with recurrent auricular hematomas and may be helpful [12].
To prevent continued bleeding, patients should also avoid aspirin and other nonsteroidal antiinflammatory drugs. For anticoagulated patients, consultation with a hematologist is warranted to guide adjustment of anticoagulant therapy after hematoma drainage. (See "Perioperative management of patients receiving anticoagulants", section on 'Overview of our approach'.)
Patients should be educated to return for treatment if swelling, redness, or pain occurs. If sutures are placed, antibiotic ointment or other emollients can be used to dress incisions and mattress sutures while bolsters should be kept clean until removed. Further care depends upon the initial treatment:
●If an indwelling intravenous (IV) catheter is present, it should be gently removed at five days and external compression applied for three to five minutes [8].
●If nonabsorbable mattress sutures are used, they should be removed at 7 to 10 days.
●Bolsters should be removed at seven days.
●Pressure dressings may be changed daily during the initial wound checks and then discontinued after 72 hours, or, in patients with an indwelling IV catheter, five days.
Prophylactic antibiotic therapy — Although evidence is lacking, because of the risk of infection to an area with tenuous blood supply, we suggest that all patients who undergo auricular hematoma drainage receive a 7 to 10 day course of empiric antibiotics with activity against skin flora and Pseudomonas aeruginosa as follows [1,4]:
●In older adolescents and adults, levofloxacin to cover skin flora and Pseudomonas aeruginosa.
●In younger children, amoxicillin and clavulanic acid to cover skin flora. Fluoroquinolones are not recommended for routine use in children <18 years of age because studies in immature animals have demonstrated the development of arthropathy with erosions of the cartilage in weight-bearing joints. (See "Fluoroquinolones", section on 'Children'.)
If infection develops after drainage while on prophylactic antibiotics, patients should be admitted for intravenous antibiotics that cover Staphylococcus aureus and Pseudomonas aeruginosa (eg, vancomycin and ceftazidime).
RETURN TO SPORTS — All patients should refrain from activity that places their ear at risk for additional trauma until the ear is healed [1]. Return to sports can occur as early as seven days after the initial injury if the hematoma does not reaccumulate [3,8]. Athletes should be strongly advised to wear protective headgear to prevent reinjury.
COMPLICATIONS — Potential complications of auricular hematoma drainage include infection, recurrence of hematoma, and cauliflower ear [7]. Infection should be treated with intravenous antibiotics. Drainage is necessary for hematomas or abscesses that develop during follow-up. (See 'Aftercare' above.)
Cauliflower ear usually poses no functional loss to hearing. However, patients who want an improved cosmetic appearance warrant referral to an otolaryngologist or plastic surgeon.
SUMMARY AND RECOMMENDATIONS
●Mechanism of injury – Auricular hematoma occurs after direct trauma to the ear, typically during sports (eg, rugby, wrestling, boxing, or mixed martial arts). If the hematoma is not drained, disruption of blood supply to the auricular cartilage causes necrosis, increases the chance of infection, and usually results in a cauliflower ear (picture 1). Wrestlers, boxers, and participants in mixed martial arts are predisposed. (See 'Anatomy and pathophysiology' above and 'Mechanism of injury' above.)
●Clinical features and diagnosis – The diagnosis of auricular hematoma or cauliflower ear is made by the characteristic clinical appearance in patients with history of blunt trauma to the auricle. Infections of the ear cartilage or inflammation from relapsing polychondritis (picture 2 and picture 3) may occasionally mimic these injuries. (See 'Clinical features and diagnosis' above and 'Differential diagnosis' above.)
●Indication for referral – Auricular hematomas that are more than seven days old warrant referral to an otolaryngologist or plastic surgeon for debridement of new perichondrial growth and any remaining hematoma. (See 'Indications for treatment and subspecialty consultation or referral' above.)
●Management – All auricular hematomas should be drained as soon as possible after injury. (See 'Indications for treatment and subspecialty consultation or referral' above.)
•Analgesia – A regional auricular block using local anesthetic, such as 1 or 2 percent buffered lidocaine with epinephrine, usually provides adequate anesthesia for auricular hematoma drainage in the cooperative patient (figure 2). The discomfort of infiltration may be further decreased by the use of nonpharmacologic interventions. (See 'Analgesia' above.)
•Equipment – The necessary equipment for drainage of an auricular hematoma is listed above. (See 'Equipment' above.)
•Choice of procedure – Our approach depends upon the size and age of the auricular hematoma. (See 'Approach' above.)
-Small hematoma – In patients with auricular hematomas that are <2 cm in diameter and present within 48 hours of injury, we suggest they undergo needle aspiration rather than either incision and drainage or evacuation using an intravascular catheter (Grade 2C). (See 'Small, acute auricular hematomas' above.)
-Large hematoma – In patients with auricular hematomas ≥2 cm in diameter or present between 48 hours and seven days after injury, we suggest they undergo either incision and drainage or evacuation using an intravascular catheter rather than needle aspiration (Grade 2C). (See 'Larger auricular hematomas' above.)
●Aftercare – After auricular hematoma drainage, patients warrant daily follow-up for three to five days to evaluate for reaccumulation of the hematoma or infection. Further care depends upon the technique used for drainage. (See 'Aftercare' above.)
●Prophylactic antibiotic therapy – In all patients who undergo auricular hematoma drainage, we suggest prophylactic antibiotic therapy (Grade 2C). We use a 7- to 10-day course of an antibiotic with activity against skin flora and Pseudomonas aeruginosa, such as levofloxacin (or amoxicillin and clavulanic acid in young children). The area has a tenuous blood supply, which increases risk of infection. (See 'Prophylactic antibiotic therapy' above.)
●Activity limitations – All patients should refrain from activity that places their ear at risk for additional trauma until the ear is healed. Return to sports can occur as early as seven days after the initial injury if the hematoma does not reaccumulate. Athletes should be strongly advised to wear protective headgear to prevent recurrence. (See 'Return to sports' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
