CLINICAL REVIEW

Tidsskr Nor Legeforen nr. 2, 2017; 137: 105 – 8

Clinical review

Auricular haematoma 105 – 8

Christoffer Aam Ingvaldsen

chingv@ous-hf.noDepartment of Plastic and Reconstructive SurgeryOslo University Hospital

Kim Alexander Tønseth

Department of Plastic and Reconstructive SurgeryOslo University Hospital

MAIN POINTS

Auricular haematoma can lead to necrosis

of cartilage

Untreated auricular haematoma can give

rise to permanent deformity, so-called

«cauliflower ear»

The recommended treatment is rapid eva-

cuation of the haematoma and subsequent

pressure dressing

Surgical correction of cauliflower ear invol-

ves difficult reconstructive plastic surgery

Auricular haematomas typically occur as a result of the auricle being

pulled or subjected to blunt trauma in association with contact sports,

accidents or violence. An auricular haematoma requires prompt surgi-

cal intervention to avoid cauliflower ear, also known as «wrestler’s ear».

A cauliflower ear is a permanent deformity made up of connective tissue

and cartilage.

The ear is supported by a scaffold composed visible swelling or because they have addi-

of several cartilaginous components: thehelix, antihelix, concha, tragus and antitragus.The skin covering this cartilage scaffold isextremely thin with virtually no subcutaneousadipose tissue, and is also strongly adherent tothe underlying perichondrium. The peri-chondrium is richly vascularized and suppliesthe avascular cartilage with blood (1).

In an auricular haematoma, blood accumu-lates in the layer between the perichondriumand cartilage. The haematoma thus forms amechanical barrier between the cartilage andits blood supply from the perichondrium (2).Deprived of sufficient nutrients, the cartilagemay become necrotic and/or infected. Thiswill eventually trigger disorderly fibrosis andcartilage formation around the various carti-laginous components (3).

As a consequence, the normally concavestructure of the ear becomes filled with con-nective tissue. The cartilage subsequentlydeforms and buckles, giving rise to variantsof so-called «cauliflower ear» (Figure 1).Rapid evacuation of the haematoma restoresclose contact between the cartilage and peri-chondrium, thereby reducing the likelihoodof deformity.

This article provides an overview of themanagement of auricular haematomas.Knowledge remains limited with respect tothe optimal technique for acute treatment(4). The literature consists of a small numberof case reports, systematic reviews and clin-ical practice guidelines.

The article is based on the authors’ ownexperience of working in the Accident andEmergency department and as plastic sur-geons, as well as on a review of the guide-lines provided by UpToDate (5) and a selec-tion of articles obtained through searches inPubMed and McMaster PLUS.

Clinical presentationAn auricular haematoma typically presentsas a tender, tense and fluctuating swelling onthe anterior surface of the ear, with mild tomoderate throbbing pain. Most patients seekmedical advice primarily because of the

tional injuries that they wish to have exam-ined (head/neck injury, lacerations etc.).

In the Accident and Emergency depart-ment, a patient with an auricular haematomawill often have many other injuries too –especially if those injuries were sustained asa result of violence. Auricular haematoma isthus easily overlooked unless a specificeffort is made to rule it out during the clini-cal examination.

The haematoma typically fills the hollowbetween the helix and the antihelix (scapha)and extends forward into the fossa triangula-ris. Less frequently, the haematoma mayoccupy the concha or the area in and aroundthe external auditory meatus. It is importantto be aware that an auricular haematomamay also occur on the posterior surface ofthe ear, or possibly on both surfaces,although this is less common (1). The risk ofnecrosis is greater if haematomas are presenton both anterior and posterior surfaces (6).

The overlying skin may have normalcolouration, or may be erythematous orecchymotic. The mechanism of injury willdetermine whether ulceration or lacerationsare present: these are more common withsharp force trauma (e.g. injuries caused byglass). The skin is usually intact and thehaematoma feels soft upon palpation. Approx-imately 24 hours post-trauma, the blood willclot and the swelling may become firmer.

It is important for the examining clinicianto rule out other serious injury in patientswith auricular haematoma, in particularhead and/or neck injury. The anamnesisshould clarify any loss of consciousness,amnesia and the use of anticoagulants. It isessential to keep in mind that the patient mayhave been subjected to violence. Otoscopyshould also be performed on both ears toexclude perforation of the eardrum andhaematotympanum (7).

TreatmentAcute evacuation is required for all auricularhaematomas (4, 5). Needle aspiration orincision and drainage can be performed by

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the GP/Accident and Emergency doctor. It isimportant for this to occur as quickly as pos-sible so that the cartilage does not becomenecrotic.

An alternative approach is required if thehaematoma is more than seven days old.Such haematomas will often be more organ-ised and more difficult to drain. There may

also be ulceration and/or necrosis of theskin, in which case the patient should bereferred to an otorhinolaryngologist or plas-tic surgeon.

Evacuation of the haematomaThe procedure should be performed underregional auricular block (5). We recommendXylocaine 1 % with adrenaline. Good resultscan also be achieved with infiltration ana-esthesia, but this should be reserved for thesmallest haematomas (less than 2 cm). Sup-plemental adrenaline is recommended withregional auricular block, but must not beused with infiltration anaesthesia (5).

It is important to disinfect the ear and thesurrounding skin first. Sterile spongesshould be moistened with chlorhexidine spi-rit 5 mg/ml (0.5 %) and applied for at leasttwo minutes. The spirit should be allowed toair dry prior to perforation of the skin.Figure 2 illustrates how to perform a regio-nal auricular block.

The recommended treatment will dependon the size and age of the auricular haema-toma (5). As stated above, if the haematomais more than seven days old, the patient mustbe referred to an otorhinolaryngologist orplastic surgeon for revision and, if neces-sary, reconstruction.

Needle aspiration is recommended if theauricular haematoma is < 2 cm in diameterand < 48 hours old. Green (21 gg) or pink(18 gg) cannulae are suitable. The insertionsite should ideally be at the base of the hae-matoma. It is not necessary to insert theneedle into or through the cartilage. If aspi-ration of the haematoma proves difficult,this is probably because the blood has fullyor partly coagulated. Incision and drainageshould then be considered.

Figure 1 An untreated auricular haematoma can lead to cauliflower ear. Above, three patients with permanent and solid cauliflower ears as a result of failure to evacuate the haematoma. Photographs: Christoffer Aam Ingvaldsen

Figure 2 Regional auricular block is indicated for the evacuation of larger auricular haematomas. This pro-vides good anaesthesia while avoiding the introduction of additional volume into the already tense and trauma-tised tissue. Xylocaine with supplemental adrenaline is injected via a thin cannula into the skin, as shown here. Two injection sites are usually sufficient. The anaesthetic is injected in a V-shape underneath the ear and an inverted V-shape above the ear. Optimal effects are achieved after ten minutes. The nerve block anaesthetises anterior and posterior surfaces of the ear in their entirety, with the exception of the area in and around the exter-nal auditory meatus, which is innervated by branches of the vagus nerve

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Incision and drainage is recommended ifthe auricular haematoma is 2 cm in dia-meter or > 48 hours old (5, 8). The incisionshould be made at the base of the haema-toma. If the haematoma is located in thescapha and/or fossa triangularis, the incisionshould be directly above the contour of theantihelix. Such incisions often yield goodcosmetic results. Alternatively, the incisionmay be made just underneath the edge ofthe helix, so that the scar will be at least par-tially hidden. The incision must be suffi-ciently large to allow evacuation of thecoagula. Figure 3 illustrates the surface ana-tomy of the ear and a typical auricularhaematoma.

Cutting down into the cartilage should beavoided: if the haematoma empties, the inci-sion is sufficiently deep. If necessary, theincision can be enlarged slightly using asmall pair of scissors or tissue forceps.When the haematoma has been drained, thearea should be rinsed with sterile saline untilthe liquid runs clear. The incision can thenbe closed with, for example, 5 – 0 non-absorbable nylon sutures. Mattress stitch isrecommended. The surgical needle mustpass through the skin, perichondrium andcartilage on both sides of the incision. Theaim is to achieve good contact between thelayers. A small area outermost in the inci-sion is left open to allow drainage.

After surgery, a pressure dressing is app-lied with the vaseline-impregnated gauzeinnermost, followed by a sterile saline dres-sing and dry bandage. It is often necessary towrap an elastic bandage around the headto ensure sufficient pressure against the sur-face of the ear.

Figure 3 Illustration of the surface anatomy of the ear and the typical location of an auricular haema-toma (in the cranial part of the scapha and extending into the fossa triangularis). The heavy lines in black are suggested incisions along the antihelix and helix

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Antibiotic prophylaxisAn area with little blood supply is vulnerableto infection. It is recommended that all pa-tients receive 7 – 10 days of antibiotic prophy-laxis (5). One option is dicloxacillin (cap-sules) 500 mg three to four times daily untilremoval of sutures; this will cover peni-cillinase-producing staphylococci, which areresponsible for numerous wound infections.

AftercareWe recommend that the wound is checkedtwo or three times over the first five days toevaluate reaccumulation of the haematomaand/or infection. The pressure dressingshould be changed each time the wound ischecked. If reaccumulation of blood hasoccurred, aspiration and/or incision can berepeated. If the incision and drainage pro-cess is complete, the pressure dressing maybe removed after three days. Sutures areremoved after 7 – 10 days.

If the patient actively participates in riskyactivities (e.g. wrestling), we recommendthat he or she abstains from such activities inthe week after treatment. The use of headprotection (scrum cap) or ear taping (oftenused in rugby) should also be encouraged.

Reconstruction of cauliflower earMany of those who take part in boxing,wrestling, martial arts and rugby do not con-sider cauliflower ears to be unsightly – quitethe opposite in fact. We have been in contactwith members of this community in Oslo,and it appears that many individuals avoidhaving haematomas drained. Cauliflowerears may form part of an image and be seenas a badge of honour. Our impression is thatonly a minority of these patients seek medi-cal advice and treatment.

Many athletes and participants in contactsports do change their minds later on in life,however, often in connection with choosing/changing careers. Some also report pain/dis-comfort when trying to sleep or when pres-sure is applied to the ear. These individualsoccasionally seek surgical correction (9).

Surgical correction of a manifest cauli-flower ear is a challenging reconstruction.Reconstruction techniques in which thedeformed connective tissue and cartilage areexcised and/or remodelled by means ofsuitable incisions are described in the litera-ture (9 – 11).

In severe cases in which most of the earcartilage has been lost, cartilage from the ribcan be used to reconstruct the cartilaginouscomponents of the ear. This type of recon-struction is performed regularly at Rikshos-pitalet in association with congenital mal-formations of the ear (anotia/microtia), buthas yet to be performed in a patient withcauliflower ear.

ConclusionGPs and staff in the Emergency Ward/Acci-dent and Emergency department shouldhave knowledge of auricular haematomasand of the importance of rapid treatment. Anauricular haematoma may lead to necrosis ofcartilage, which will leave the patient at riskof ulceration and cauliflower ear. The cli-nician who examines the patient shouldattempt to evacuate the haematoma (ratherthan referring the patient onwards), asprompt treatment reduces the risk of perma-nent deformity.

The optimal method for evacuating ahaematoma is dependent on the size and ageof the haematoma. If the clinician is uncom-fortable with applying a regional auricularblock and/or making an incision in the ear,needle aspiration under sterile conditionsmay be attempted instead. It may be possibleto perform needle aspiration without auri-cular block or infiltration anaesthesia. If thepatient consents, such treatment is betterthan waiting and potentially allowing thecartilage to become necrotic.

Patients with older auricular haematomasor manifest cauliflower ears should be refer-red to an otorhinolaryngologist or plasticsurgeon for treatment and assessment ofoptions for reconstruction.

Christoffer Aam Ingvaldsen (born 1990)

doctor with experience in the Oslo Accident

and Emergency department, and researcher.

The author has completed the ICMJE form

and reports no conflicts of interest.

Kim Alexander Tønseth (born 1974)

specialist in plastic surgery and head of depart-

ment.

The author has competed the ICMJE form

and reports no conflicts of interest.

References

1. Shakeel M, Vallamkondu V, Mountain R et al. Open surgical management of auricular haema-toma: incision, evacuation and mattress sutures. J Laryngol Otol 2015; 129: 496 – 501.

2. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear. Facial Plast Surg 2010; 26: 451 – 5.

3. Giffin CS. Wrestler's ear: pathophysiology and treatment. Ann Plast Surg 1992; 28: 131 – 9.

4. Jones SE, Mahendran S. Interventions for acute auricular haematoma. Cochrane Database Syst Rev 2004; 2: CD004166.

5. Malloy KM. Assessment and management of auri-cular hematoma and cauliflower ear. UpToDate-versjon 9.9.2015. www.uptodate.com/contents/assessment-and-management-of-auricular-hematoma-and-cauliflower-ear (4.9.2016).

6. Eagles K, Fralich L, Stevenson JH. Ear trauma. Clin Sports Med 2013; 32: 303 – 16.

7. Cassaday K, Vazquez G, Wright JM. Ear problems and injuries in athletes. Curr Sports Med Rep 2014; 13: 22 – 6.

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8. Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol 2010; 31: 21 – 4.

9. Vogelin E, Grobbelaar AO, Chana JS et al. Surgical correction of the cauliflower ear. Br J Plast Surg 1998; 51: 359 – 62.

10. Yotsuyanagi T, Yamashita K, Urushidate S et al. Surgical correction of cauliflower ear. Br J Plast Surg 2002; 55: 380 – 6.

11. Fujiwara M, Suzuki A, Nagata T et al. Cauliflower ear dissection. J Plast Reconstr Aesthet Surg 2011; 64: e279 – 82.

Received 28 November 2015, first revision sub-mitted 19 June 2016, accepted 26 October 2016. Editor: Liv-Ellen Vangsnes.

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