Auricular Haematoma 105 – 8

CLINICAL REVIEW Clinical review Auricular haematoma 105 – 8 Auricular haematomas typically occur as a result of the auricle being Christoffer Aam Ingvaldsen [email protected] pulled or subjected to blunt trauma in association with contact sports, Department of Plastic and Reconstructive Surgery accidents or violence. An auricular haematoma requires prompt surgi- Oslo University Hospital Kim Alexander Tønseth cal intervention to avoid cauliflower ear, also known as «wrestler’s ear». Department of Plastic and Reconstructive Surgery A cauliflower ear is a permanent deformity made up of connective tissue Oslo University Hospital and cartilage. The ear is supported by a scaffold composed visible swelling or because they have addi- MAIN POINTS of several cartilaginous components: the tional injuries that they wish to have exam- helix, antihelix, concha, tragus and antitragus. ined (head/neck injury, lacerations etc.). Auricular haematoma can lead to necrosis The skin covering this cartilage scaffold is In the Accident and Emergency depart- of cartilage extremely thin with virtually no subcutaneous ment, a patient with an auricular haematoma Untreated auricular haematoma can give adipose tissue, and is also strongly adherent to will often have many other injuries too – rise to permanent deformity, so-called the underlying perichondrium. The peri- especially if those injuries were sustained as «cauliflower ear» chondrium is richly vascularized and supplies a result of violence. Auricular haematoma is the avascular cartilage with blood (1). thus easily overlooked unless a specific The recommended treatment is rapid eva- In an auricular haematoma, blood accumu- effort is made to rule it out during the clini- cuation of the haematoma and subsequent lates in the layer between the perichondrium cal examination. pressure dressing and cartilage. The haematoma thus forms a The haematoma typically fills the hollow Surgical correction of cauliflower ear invol- mechanical barrier between the cartilage and between the helix and the antihelix (scapha) its blood supply from the perichondrium (2). and extends forward into the fossa triangula- ves difficult reconstructive plastic surgery Deprived of sufficient nutrients, the cartilage ris. Less frequently, the haematoma may may become necrotic and/or infected. This occupy the concha or the area in and around will eventually trigger disorderly fibrosis and the external auditory meatus. It is important cartilage formation around the various carti- to be aware that an auricular haematoma laginous components (3). may also occur on the posterior surface of As a consequence, the normally concave the ear, or possibly on both surfaces, structure of the ear becomes filled with con- although this is less common (1). The risk of nective tissue. The cartilage subsequently necrosis is greater if haematomas are present deforms and buckles, giving rise to variants on both anterior and posterior surfaces (6). of so-called «cauliflower ear» (Figure 1). The overlying skin may have normal Rapid evacuation of the haematoma restores colouration, or may be erythematous or close contact between the cartilage and peri- ecchymotic. The mechanism of injury will chondrium, thereby reducing the likelihood determine whether ulceration or lacerations of deformity. are present: these are more common with This article provides an overview of the sharp force trauma (e.g. injuries caused by management of auricular haematomas. glass). The skin is usually intact and the Knowledge remains limited with respect to haematoma feels soft upon palpation. Approx- the optimal technique for acute treatment imately 24 hours post-trauma, the blood will (4). The literature consists of a small number clot and the swelling may become firmer. of case reports, systematic reviews and clin- It is important for the examining clinician ical practice guidelines. to rule out other serious injury in patients The article is based on the authors’ own with auricular haematoma, in particular experience of working in the Accident and head and/or neck injury. The anamnesis Emergency department and as plastic sur- should clarify any loss of consciousness, geons, as well as on a review of the guide- amnesia and the use of anticoagulants. It is lines provided by UpToDate (5) and a selec- essential to keep in mind that the patient may tion of articles obtained through searches in have been subjected to violence. Otoscopy PubMed and McMaster PLUS. should also be performed on both ears to exclude perforation of the eardrum and Clinical presentation haematotympanum (7). An auricular haematoma typically presents as a tender, tense and fluctuating swelling on Treatment the anterior surface of the ear, with mild to Acute evacuation is required for all auricular moderate throbbing pain. Most patients seek haematomas (4, 5). Needle aspiration or medical advice primarily because of the incision and drainage can be performed by Tidsskr Nor Legeforen nr. 2, 2017; 137: 105 – 8 105 CLINICAL REVIEW 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 the GP/Accident and Emergency doctor. It is An alternative approach is required if the also be ulceration and/or necrosis of the important for this to occur as quickly as pos- haematoma is more than seven days old. skin, in which case the patient should be sible so that the cartilage does not become Such haematomas will often be more organ- referred to an otorhinolaryngologist or plas- necrotic. ised and more difficult to drain. There may tic surgeon. Evacuation of the haematoma The procedure should be performed under regional auricular block (5). We recommend Xylocaine 1 % with adrenaline. Good results can also be achieved with infiltration anaesthesia, but this should be reserved for the smallest haematomas (less than 2 cm). Sup- plemental adrenaline is recommended with regional auricular block, but must not be used with infiltration anaesthesia (5). It is important to disinfect the ear and the surrounding skin first. Sterile sponges should be moistened with chlorhexidine spirit 5 mg/ml (0.5 %) and applied for at least two minutes. The spirit should be allowed to air dry prior to perforation of the skin. Figure 2 illustrates how to perform a regional auricular block. The recommended treatment will depend on the size and age of the auricular haematoma (5). As stated above, if the haematoma is more than seven days old, the patient must be referred to an otorhinolaryngologist or plastic surgeon for revision and, if necessary, reconstruction. Needle aspiration is recommended if the auricular haematoma is < 2 cm in diameter and < 48 hours old. Green (21 gg) or pink (18 gg) cannulae are suitable. The insertion site should ideally be at the base of the hae- Figure 2 Regional auricular block is indicated for the evacuation of larger auricular haematomas. This pro- matoma. It is not necessary to insert the vides good anaesthesia while avoiding the introduction of additional volume into the already tense and trauma- needle into or through the cartilage. If aspi- 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 ration of the haematoma proves difficult, inverted V-shape above the ear. Optimal effects are achieved after ten minutes. The nerve block anaesthetises this is probably because the blood has fully anterior and posterior surfaces of the ear in their entirety, with the exception of the area in and around the exter- or partly coagulated. Incision and drainage nal auditory meatus, which is innervated by branches of the vagus nerve should then be considered. 106 Tidsskr Nor Legeforen nr. 2, 2017; 137 CLINICAL REVIEW Antibiotic prophylaxis Conclusion An area with little blood supply is vulnerable GPs and staff in the Emergency Ward/Acci- to infection. It is recommended that all pa- dent and Emergency department should tients receive 7 – 10 days of antibiotic prophy- have knowledge of auricular haematomas laxis (5). One option is dicloxacillin (cap- and of the importance of rapid treatment. An sules) 500 mg three to four times daily until auricular haematoma may lead to necrosis of removal of sutures; this will cover peni- cartilage, which will leave the patient at risk cillinase-producing staphylococci, which are of ulceration and cauliflower ear. The cli- responsible for numerous wound infections. nician who examines the patient should attempt to evacuate the haematoma (rather Aftercare than referring the patient onwards), as We recommend that the wound is checked prompt treatment reduces the risk of perma- two or three times over the first five days to nent deformity. evaluate reaccumulation of the haematoma The optimal method for evacuating a and/or infection. The pressure dressing haematoma is dependent on the size and age should be changed each time the wound is of the haematoma. If the clinician is uncom- checked. If reaccumulation of blood has fortable with applying a regional auricular occurred, aspiration and/or incision can be block and/or making an incision in the ear, Figure 3 Illustration of the surface anatomy of the repeated. If the incision and drainage pro- needle aspiration under sterile conditions ear and the typical location of an auricular haema- cess is complete, the pressure dressing may may be attempted instead. It may be possible toma (in the cranial part of the scapha and extending be removed after three days. Sutures are to perform needle aspiration without auri- into the fossa triangularis). The heavy lines in black removed after 7 – 10 days. cular block or infiltration anaesthesia. If the are suggested incisions along the antihelix and helix If the patient actively participates in risky patient consents, such treatment is better activities (e.g. wrestling), we recommend than waiting and potentially allowing the that he or she abstains from such activities in cartilage to become necrotic.

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