Auricular hematomas are caused by direct blunt trauma to the anterior auricle, occurring most commonly in wrestlers, boxers, and rugby players. Trauma can cause a hematoma that separates the auricular perichondrium from the underlying cartilage and interrupts blood vessels that nourish the cartilage. If the perichondrium and its vessels are not reattached to the cartilage, there can be scarring and permanent deformity of the cartilage (cauliflower ear Subperichondrial hematoma (cauliflower ear) Trauma to the external ear may result in hematoma, laceration, avulsion, or fracture. The perichondrium supplies blood to the auricular cartilage. Blunt trauma to the pinna may cause a subperichondrial... read more ).
The goal of treatment is complete evacuation of the subperichondrial hematoma and replacement of the perichondrium back onto the cartilage surface to facilitate readhesion and prevent reaccumulation of the hematoma and cartilage malformation.
Needle aspiration of an auricular hematoma is no longer recommended due to the high risk of reaccumulation of the hematoma. This procedure focuses only on incision and drainage.
Tender focal swelling on the pinna within 7 days after trauma.
If it has been longer than 7 days since the injury, the patient should be referred to an otolaryngologist.
Unrepaired laceration, particularly with exposed cartilage (repair the cartilage and laceration)
Chronic or recurrent hematoma (refer to an otolaryngologist)
Reaccumulation of the hematoma, which can lead to scar formation and cauliflower ear Subperichondrial hematoma (cauliflower ear) Trauma to the external ear may result in hematoma, laceration, avulsion, or fracture. The perichondrium supplies blood to the auricular cartilage. Blunt trauma to the pinna may cause a subperichondrial... read more
Antiseptic solution (eg, chlorhexidine, povidone iodine)
Lidocaine 1%, without epinephrine, 3-mL syringe, 25-gauge needle
Hemostat or other tool for dissection
Syringe and sterile normal saline
Optional: Sterile mineral oil
Compression/bolster dressing material: Dental rolls, dry cotton, petrolatum gauze, or 4 × 4 plain gauze, gauze wrap dressing, tape
Hematomas may be anterior, posterior, or both.
The skin of the auricle is normally densely adherent to the perichondrium, and if it is not held down with pressure, the cartilage below can necrose or deform over time.
The cartilage configuration of the auricle is relatively symmetric in most people, and this can help determine where to apply bolstering of a large anterior hematoma.
For a posterior hematoma: Lateral decubitus position on the unaffected side
For an anterior hematoma: Supine with a slight head turn to the unaffected side
Step-by-Step Description of Procedure
Cleanse the pinna and adjacent skin with antiseptic solution.
Anesthetize the pinna with 1% lidocaine without epinephrine using an auricular block or direct infiltration around the hematoma. Topical anesthesia may be provided with lidocaine-prilocaine cream in addition or as an alternative method.
Incise the skin along the posterior edge of the hematoma using the #15 scalpel blade. Follow the curvature of the pinna in a skin crease or at the edge of a change in the cartilage shape to hide the scar.
Gently separate the skin and overlying perichondrium from the hematoma and underlying cartilage using the hemostat or other tool.
Evacuate the hematoma completely.
Irrigate the hematoma pocket with sterile normal saline.
Dry the area using gauze.
Apply antibiotic ointment to the incision edge.
Gently press the perichondrium back onto the cartilage with a finger; the pressure dressing will keep them in close proximity.
Place dry cotton into the external auricular canal.
Fill all external auricular crevices with petrolatum gauze or with dental rolls or gauze moistened with sterile saline or mineral oil.
Hematomas that are both anterior and posterior require the bolsters to be sutured together with monofilament suture; dental rolls are particularly suited for this maneuver.
Place several layers of gauze behind the ear to support the back of the ear against the pressure dressing. Cut a V-shape or curve out of the gauze first to allow for a close fit to the ear.
Cover the external ear with multiple layers of fluffed-up 4 × 4 gauze, and hold them in place by wrapping elastic or gauze bandages around the head and taping the bottom edge of the dressing over the ear lobule.
Prescribe oral antibiotics that cover staphylococcus for 7 days.
The dressing should be kept dry for 1 week; a shower cap should be used when bathing.
Remove the dressing in 1 week.
Reevaluate for recurrence of the hematoma 24 hours after removal of the dressing.
Patients should not manipulate the ear for 1 month after the dressing is removed to optimize healing and cosmetic result.
Warnings and Common Errors
The pressure dressing must be snug enough to prevent hematoma recurrence and/or fluid accumulation, but not so tight as to impede circulation. Typically, if the patient feels the dressing is increasing the pain or causing a headache, the dressing is too tight and should be loosened. If the patient does not feel pressure on the ear after the wrap is placed, it is too loose.
Tips and Tricks
Adequate anesthesia is needed for proper positioning of the perichondrium after hematoma evacuation.
The cotton or gauze bolsters should be placed in small pieces to conform precisely to the shape of the ear cartilage. This presses the perichondrium firmly against the cartilage, allowing it to heal without reaccumulation of the hematoma or deformity.
A properly applied head wrapping impinges uncomfortably on the patient's eyebrow and contralateral ear. This can be made more tolerable by wrapping umbilical tape or an unfolded 4 × 4 gauze around the dressing above the eye and opposite ear to bunch it up and hold it clear of the eye and ear.