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It’s midnight on a Friday and your next patient just happens to have been on the wrong end of a left hook. He is a 62 year old man who states he was assaulted with a fist to the face while walking home. He denies loss of consciousness and has been drinking. His only complaints at this time are right ear pain and some lateral neck pain. He has no other past medical history. His vitals are unremarkable. His exam is notable for some peculiar swelling of his right ear and alcohol intoxication. His tympanic membrane is unremarkable and the rest of a thorough trauma evaluation yields nothing. The good news is that you’re his doctor and his ear will soon be returned to its prior state, ready to face another day.

Auricular hematoma occurs when blunt shearing force is sustained to the ear, often times in cases of facial trauma or in sports like boxing, wrestling, and mixed martial arts. These forces separate the underlying perichondrium from the cartilage itself. This area is highly vascularized and bleeding between this space results in the formation of hematoma. The disruption of the blood flow to the cartilage from this injury subsequently leads to necrosis1.

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Auricular hematoma occurs when blood accumulates between the perichondrium and cartilage of the ear

Our job in the emergency department is three fold: early identification, early drainage, and using various splints and bandaging techniques to prevent the re-accumulation of blood.
Thorough traumatic evaluation of the ear should be performed. This includes examination of the anterior and posterior aspect of the pinna and otoscopic evaluation as blunt trauma to the ear can often lead to tympanic membrane rupture. Early identification of auricular hematoma is paramount as the natural history of these injuries includes cartilage necrosis and subsequent fibrous deposition leading to a cauliflower ear deformity that later may require surgical excision. Spontaneous infection has also been described and if cartilage is exposed then antibiotics should be considered1.

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An incision made to the top of the hematoma allows for better cosmetic healing as the scar will be concealed by the superior aspect of the helix

Drainage of auricular hematomas is the definitive treatment.  Regional anesthesia is best achieved with a greater auricular nerve block. To obtain the best cosmetic result, an incision is made to the superior aspect of the helix as pictured above. Blood can then be expressed from ear with manual compression. Further clotted blood can be easily broken up and removed with curved hemostats.

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Curved hemostats help evacuate clotted blood left behind

Several methods of dressing and splinting have been described in the literature to prevent the accumulation of blood after drainage. Buttressing the ear by sewing cotton pledgets was first used in the eighties. This idea was later modified to use buttons sewn to the anterior and posterior aspects of the ear1. These techniques however can be time consuming and cumbersome.

alt Specialized thermoplastic splints were developed and can be formed to the ear. These do well in preventing re-accumulation, but can be expensive. In further researching this subject, we found that simply placing two to three absorbable mattress sutures along the involved portion of ear both prevents accumulation of blood and spares the patient buttresses that require future removal2,3. Finally a compressive dressing should be applied. This is best achieved by supporting the posterior aspect of the ear with gauze.  Wrapping the head is a good way to keep the dressing in place.

So now you are set. By utilizing the three tenets described above, there is no longer reason to fear the ear.
Dressing should be placed both posterior and anterior to the ear as to maintain pressure

References
1. Greywoode J, Pribitkin E, Krein H. Management of Auricular Hematoma and the Cauliflower Ear. Facial Plast Surg. 2010;Vol 26;6:451-455.
2. Soham Roy, Lee P. Smith. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol. 2010 Jan-Feb;31(1):21-24.
3. Giles WC, Iverson KC, Kind JD, Hill FC, Woody EA, Bouknight AL. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007 Dec;117(12):2097-9.

Drs. Christopher Johnston, Lina Tran and Erik Adler are 3rd and 4th year EM Residents at the Denver Health Emergency Medicine Residency Program. Dr. Peter Pryor is an Assistant Professor of EM at the University of Colorado School of Medicine.

 

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