Mastering Minor Care: Auricular Hematoma
/Background:
Auricular hematomas commonly occur in wrestlers, boxers, and mixed-martial artists. They result from shearing of the perichondrium from the underlying cartilage, resulting in tearing of blood vessels and hematoma formation. (1) Continued loss of blood flow to the cartilage eventually leads to necrosis, thereby increasing the risk for cellulitis, perichondritis, and poor wound healing resulting in ‘cauliflower ear.’ (1)
Fig 1. Auricular Ring Block anesthetizes the AuriculoTemporal Nerve (superior portion of the ear), the lesser occipital nerve (Middle portion of the ear), and the greater auricular nerve (inferior portion of the ear)
Treating an auricular hematoma presents an interesting challenge to the emergency provider because there are multiple management options. However, the main principles are to completely evacuate the hematoma and dress the wound in a manner that prevents reaccumulation of blood.
Management:
Steps for Evacuating an Auricular Hematoma
Anesthetize the area with 1% Lidocaine by performing an auricular ring block (Figure 1); a video demonstration for this technique can also be found here.
Clean the area with Betadine or Chlorhexidine and drape the affected ear with surgical towels
Make an incision through the skin and perichondrium along the lines of tension following the curvature of the pinna using an 11-blade scalpel
Evacuate the hematoma with gentle pressure and irrigation with sterile saline
Dress the wound (as below)
Dressing Approach:
Bolster-less technique: Place non-absorbable or absorbable mattress sutures to re-approximate the incision. Apply a liberal amount of antibacterial ointment to the incision and leave it open to air. (2)
Bolster technique: Create a bolster dressing that conforms to the shape of the ear using petrolatum gauze. Add gauze padding posterior to the ear. (Figure 2). Wrap a compressive gauze or bandage roll around the head. Alternatively, one can also place cotton dental rolls coated with antibiotic ointment on the anterior and posterior sides of the hematoma and secure them in place using non-absorbable mattress sutures. (3)
Antibiotic ointment should be placed on the incision site regardless of the dressing technique. Additionally, a one-week course of oral antibiotics is traditionally recommended with coverage of pseudomonal species.
Figure 2. Bolster dressing with petroleum gauze with posterior gauze padding
Discussion:
The ideal approach to managing an auricular hematoma is one that consists of complete evacuation of the hematoma and a dressing that prevents the re-accumulation of blood. While there are many ways to drain the hematoma, needle aspiration has generally resulted in increased chance of re-accumulation when compared to incision and drainage (I&D). (4,5) Small hematomas (<2cm) are potentially amenable to needle aspiration alone, however anything larger almost certainly requires I&D. (6) If the provider feels comfortable that they’ll be able to completely evacuate the hematoma using needle aspiration, it is acceptable to proceed with this approach. However, if there is any uncertainty, then the I&D approach should be utilized.
There are many ways discussed in literature to compress the incision site. Traditionally, a bolster dressing that fills the auricular grooves combined with a compressive roll around the head has been used. While this approach is sufficient, there is still a risk for re-accumulation of the hematoma. Additionally, the bulky dressings often prevent the athletes from returning to sports. Not to mention, there is the risk of non-compliance with dressing care.
An alternate approach to dressing the incision site is to apply cotton dental rolls to the anterior and posterior aspects of the hematoma. (3,7) One study found a decreased risk of re-accumulation for this approach when compared to I&D and a traditional bolster dressing. (7) Furthermore, this alternate approach allows the athlete to return to sports more quickly and requires less dressing care thereby reducing the risk of non-compliance.
Another technique that has shown promising results is placing absorbable or non-absorbable mattress sutures to coapt the skin and perichondrium to the underlying cartilage, without an accompanying compression dressing. (2,5,8) The close approximation allowed by the sutures yields a comparable, if not better, outcome than the bulky dressing approach. One study concluded that mattress sutures resulted in no hematoma recurrences with satisfactory cosmetic outcome. (2) Yet another study concluded similar results with no reaccumulation with faster return to sports. (8)
Varying techniques have been described in literature for managing these injuries. While the literature available isn’t of the highest quality, the general trend is that there are a multitude of safe approaches to wound dressing as long as some approximation attempt is made.
Follow-Up:
Most dressings need to be left in place for 7 days and can be removed by an otolaryngologist (ENT), emergency medicine provider, or a primary care physician. However, if the patient presents to the ED more than 7 days after onset of the hematoma, they should be referred to an ENT office for evaluation due to the likely formation of granulation tissue. [4]
AUTHORED BY HAMZA IJAZ, MD
Dr. Ijaz is a PGY-2 in Emergency Medicine at the University of Cincinnati
POST AND PEER EDITING BY SHAN MODI, MD
Dr. Modi is a PGY-4 in Emergency Medicine at the University of Cincinnati and Resident Editor of the ‘Minor Care Series’
FACULTY EDITING BY EDMOND HOOKER, MD, DRPH
Dr. Hooker is an Assistant Professor of Emergency Medicine at the University of Cincinnati and Faculty Editor of the ‘Minor Care Series’
References:
Hosmer K. “Ear Disorders.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9E. Judith E. Tintinalli. New York, NY: McGraw-Hill.
Kakarala K, Kieff DA. (2012). Bolsterless management for recurrent auricular hematoma. The Laryngoscope, 122(6), 1235–1237. doi: 10.1002/lary.23288
Schuller DE, Dankle SD, Strauss RH. (1989). A Technique to Treat Wrestlers Auricular Hematoma Without Interrupting Training or Competition. Archives of Otolaryngology - Head and Neck Surgery, 115(2), 202–206. doi: 10.1001/archotol.1989.01860260076018
Riviello RJ. “Otolaryngologic Procedures.” Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 7E. Philadelphia, PA: Elsevier.
Giles WC, Iverson KC, King JD, Bouknight AL. (2007). Incision and Drainage Followed by Mattress Suture Repair of Auricular Hematoma. The Laryngoscope, 117(12), 2097–2099. doi: 10.1097/mlg.0b013e318145386c
Eagles K, Fralich L, Stevenson JH. (2013). Ear Trauma. Clinics in Sports Medicine, 32(2),303–316. doi: 10.1016/j.csm.2012.12.011
Sbaihat AS, Khatatbeh WJ. (2011). Treatment of Auricular Hematoma Using Dental Roll Splints. Journal of Royal Medical Services, 18(2), 22-25. Accessed from: http://rmsjournal.org/Articles/635928584403476640.pdf
Roy S, Smith LP. (2010). A novel technique for treating auricular hematomas in mixed martial artists(ultimate fighters). American Journal of Otolaryngology, 31(1) 21–24. doi: 10.1016/j.amjoto.2008.09.005
