Auricular Hematoma Drainage
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Auricular hematoma, shown below, is a complication that results from direct trauma to the anterior auricle and is a common facial injury in wrestlers. [1, 2, 3] Shearing forces to the anterior auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. This may lead to tearing of the perichondrial blood vessels and subsequent hematoma formation.
The torn perichondrial vessels compromise the viability of the avascular underlying cartilage. Interestingly, the presence of a subperichondrial hematoma has been found to stimulate new and often asymmetric cartilage to form. [4] This deformity, which is often referred to as cauliflower ear or wrestler’s ear (shown in the image below), is often considered a badge of honor among wrestlers and rugby players. [5]
The goal of treatment is to completely evacuate subperichondrial blood and to prevent its reaccumulation. The mechanism of hematoma drainage has been debated. To date, no randomized controlled trials have addressed this issue. [6]
The auricle and external acoustic meatus (or external auditory canal) compose the external ear. The external ear functions to collect and amplify sound, which then gets transmitted to the middle ear. The asymmetric shape of the external auricle introduces delays in the path of sound that assist in sound localization.
The arterial supply of the auricle is composed of the posterior auricular artery, the anterior auricular branch of the superficial temporal artery, and the occipital artery, which also contributes. Veins accompany the corresponding named arteries.
For more information about the relevant anatomy, see Ear Anatomy.
See the list below:
Tender anterior auricular swelling after trauma, which deforms the normal anatomy of the pinna
Presentation within 7 days after trauma (After 7 days, the formation of granulation tissue may complicate the procedure. At that point, patients should be referred to a specialist.)
The procedure is contraindicated in the following cases:
Hematomas that are older than 7 days
Recurrent or chronic hematomas (In such cases, open surgical debridement by a specialist is indicated because the hematoma, granulation tissue, or both can be located within the cartilage instead of in the subperichondrial space.)
See the list below:
Local anesthesia with lidocaine 1% with or without epinephrine can be infiltrated directly into the area to be incised.
Many authors advocate the use of the lidocaine without the presence of a vasoconstrictive agent such as epinephrine. However, some literature supports the safety of vasoconstrictive agents in areas such as the nose or pinna.
Alternatively, an auricular block can be performed. For more information, see Ear Anesthesia.
See the list below:
Syringe, 3 mL, with a 23- or 27-gauge (ga) needle for anesthesia
Syringe, 10 mL, with a 18- or 20-ga needle (if performing needle aspiration)
Lidocaine 1% (with or without epinephrine)
Scalpel, No. 15
Small suction, if available
Irrigation set-up (syringe, normal saline)
Compression dressing materials
Simple compression dressing, as shown in the image below: dry cotton, Vaseline gauze, 4 x 4 plain gauze, secondary dressing wrap (eg, Kling), scissors
Specialized compression dressing (to be made in a specialist’s office; not described here): dental rolls (or cotton bolsters, silicone splints, or plaster mold), nylon or Prolene suture on straight needle
See the list below:
Place patient in the lateral decubitus position on the unaffected side.
See the list below:
Cleanse the skin with povidone iodine, ChloraPrep (chlorhexidine gluconate 2% and isopropyl alcohol 70%), or another cleanser.
Anesthetize the area with lidocaine 1% or perform an auricular block. (For more information, see Ear Anesthesia.)
Technique 1 – Needle aspiration
Although still widely used, this method is no longer recommended by many sources because of hematoma reaccumulation. The aspiration is often inadequate and the hematoma requires additional management. [7] Some sources recommend primary needle aspiration followed by the incision method, if reaccumulation occurs.
Use an 18- or 20-ga needle to aspirate blood from the most fluctuant or full area.
Technique 2 – Incision and drainage
Incise the edge of hematoma along the natural skin folds using a No. 15 scalpel. A small (5 mm) incision is often all that is necessary.
Gently separate the skin and perichondrium from the hematoma and cartilage and completely express or suction out the hematoma, as shown below. Be careful not to damage the perichondrium.
Irrigate the pocket with normal saline with an 18-ga angiocatheter.
Optional step: Leave a small drain in the incision. This allows the wound to drain but also predisposes to infection. If a drain is placed, the patient should always be given antibiotics upon discharge. The drain should be removed in 24 hours if no significant bleeding occurs.
Reapproximate the perichondrium to the cartilage.
Apply digital pressure for 5-10 minutes, and then apply compression dressing. A simple dressing is inadequate, as the hematoma is likely to reaccumulate.
Compression dressing can be applied noninvasively (more applicable in the ED) or surgically. Noninvasive methods include a simple compression dressing or, if available, application of silicone splints or plaster mold to the medial and lateral aspects of the auricle, as shown below.
Surgical dressing involves securing cotton bolsters, buttons, or thermoplastic splints [8] with through and through sutures to the medial and lateral aspects of the auricle.
A simple compression dressing can be quickly made as follows:
Place dry cotton into the external canal, as shown below.
Fill all external auricular crevices with either moist gauze (soaked in saline) or Vaseline gauze, as depicted in the image below.
Place 3-4 layers of gauze behind the ear as a posterior gauze pack. Prior to placement, cut out a V-shaped section of gauze so that the gauze fits snugly behind the ear, as shown below.
Cover the packed anterior ear as shown below, with multiple layers of fluffed gauze.
Bandage the fluffed gauze into place with Kling or an elastic bandage, as shown in the image below.
See the list below:
The ear must be reexamined for hematoma reoccurrence every 24 hours for several days.
Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants should be discontinued or avoided for several days to prevent continuing bleeding.
Recommendations indicate that, upon discharge, patients should receive antibiotics that cover common skin flora for 7-10 days. Patients whose immune systems are compromised should receive antibiotic prophylaxis covering both Staphylococcus and Pseudomonas species.
If infections suspicious for Pseudomonas species are discovered during follow-up, the patient should be admitted to the hospital for open drainage and intravenous antibiotics.
See the list below:
Do not leave an auricular hematoma undrained unless the injury is older than 7 days.
Apply a compression dressing rather than a simple dressing.
Perform daily follow-up ear examinations.
Complications may include the following:
Reaccumulation of the hematoma [4]
Site infection
Chondritis
Scar formation (cauliflower ear) [4]
Overview
What is the goal of auricular hematoma treatment?
What is the anatomy of the external ear relevant to auricular hematoma?
What are indications for auricular hematoma drainage?
What are contraindication for auricular hematoma drainage?
What is the role of anesthesia in auricular hematoma drainage?
What equipment is needed to perform auricular hematoma drainage?
How is the patient positioned for auricular hematoma drainage?
How are patients prepped for auricular hematoma drainage?
What is the role of needle aspiration in auricular hematoma drainage?
How are incision and drainage of auricular hematoma performed?
What are the procedures for compression dressing following auricular hematoma drainage?
What are procedures for surgical dressing following auricular hematoma drainage?
What is included in postoperative care of auricular hematoma drainage?
What are clinical pearls for auricular hematoma drainage?
What are the possible complications of auricular hematoma drainage?
Giffin CS. Wrestler’s ear: pathophysiology and treatment. Ann Plast Surg. 1992 Feb. 28(2):131-9. [Medline].
Schuller DE, Dankle SD, Strauss RH. A technique to treat wrestlers’ auricular hematoma without interrupting training or competition. Arch Otolaryngol Head Neck Surg. 1989 Feb. 115(2):202-6. [Medline].
Mudry A, Pirsig W. Auricular hematoma and cauliflower deformation of the ear: from art to medicine. Otol Neurotol. 2009 Jan. 30(1):116-20. [Medline].
Giles WC, Iverson KC, King 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. [Medline].
Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol. 2010 Jan-Feb. 31(1):21-4. [Medline].
Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear. Facial Plast Surg. 2010 Dec. 26(6):451-5. [Medline].
Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope. 2005 Jul. 115(7):1251-5. [Medline].
Henderson JM, Salama AR, Blanchaert RH Jr. Management of auricular hematoma using a thermoplastic splint. Arch Otolaryngol Head Neck Surg. 2000 Jul. 126(7):888-90. [Medline].
Bailey B, Calhoun K. Atlas of Head and Neck Surgery – Otolaryngology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001. 456-7.
Davidson, TM. Ambulatory Healthcare Pathways for Ear, Nose, and Throat Disordershttp://drdavidson.ucsd.edu/Portals/0/Ambuindex.htm. UCSD Otolaryngology – Head & Neck Surgery. Available at http://drdavidson.ucsd.edu/. Accessed: July 28, 2006.
Kelly TF, Suby JS. Wrestling. Mellon MB. Team Physician’s Handbook. 3rd ed. Philadelphia, Pa: Hanley & Belfus; 2002. 614-28.
Lalwani A. Diseases of External Ear. Current Diagnosis & Treatment in Otolaryngology-Head & Neck Surgery. Philadelphia, Pa: McGraw-Hill; 2004.
Lane SE, Rhame GL, Wroble RL. A silicone splint for auricular hematoma. The Physician and Sports Medicine. 1998. 26(9):77.
Roberts JR, Hedges J, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2003. 1299-1300.
Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004. 1470.
Inna Leybell, MD Clinical Assistant Professor, Department of Emergency Medicine, NYU Langone Medical Center
Inna Leybell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Student Association/Foundation, Phi Beta Kappa
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Prajoy P Kadkade, MD Assistant Professor of Otolaryngology, Albert Einstein College of Medicine; Attending Physician, Department of Otolaryngology and Communicative Disorders, Director of Otolaryngology, North Shore University Hospital, North Shore-Long Island Jewish Hospital System
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Medical Society of the State of New York
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Moira Davenport, MD, Christopher McStay, MD, Beno Oppenheimer, MD, and Linda Regan, MD, to the development and writing of this article.
Auricular Hematoma Drainage
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