An auricular hematoma is a collection of blood underneath the perichondrium of the ear typically secondary to trauma. This medical disease, commonly known as “cauliflower ear,” is infamously associated with wrestlers and other contact sports. It is important to recognize and drain this collection as persistent hematoma can cause cartilage destruction with subsequent deformity of the ear. Treatment involves drainage and evacuation of the hematoma either at the bedside or in the operating room. To prevent accumulation, it is important to place a bolster dressing to close the potential space. Consultation with ENT or plastic surgery is beneficial as they can provide recommendations regarding diagnosis, management, and follow up.
Auricular hematoma is typically caused by trauma. This can be from multiple forms of trauma including follow-up forces such as earring placement or, more commonly, larger forces such as motor vehicle accidents. It is most commonly secondary to contact sports such as wrestling, boxing, and martial arts.
The exact epidemiology is not well studied; however contact sports such as wrestling, mixed martial arts, ultimate fighting, rugby, and boxing are sports that may more readily predispose to such injuries. It can be deduced that this places males at a higher risk than females; however, the exact ratio is not known. In a survey of college wrestlers, the incidence of auricular hematoma was found to be 52% versus 26% for those refusing to wear headgear. This places them at a higher risk of developing cauliflower ear.
The auricle is made up of skin, subcutaneous tissue, musculature, and perichondrium which is the blood supply to the underlying cartilage. An auricular hematoma is a collection of blood between the perichondrium and cartilage. The primary areas of cartilage in the ear include the tragus, helix, antihelix, triangular fossa, cymba concha, and concha cavum. The blood vessels that supply the ear consist of the superficial temporal and posterior auricular artery. With trauma to the ear, the perichondrium and vasculature are damaged, causing separation from the underlying cartilage and resulting in a potential space for blood to accumulate. Once blood fills this space, it causes vascular compromise and venous congestion that can result in histologic changes of the cartilage and ensuing cartilage deformity, resulting in an unsightly appearance of the external ear known as cauliflower ear. A process of neocartilage development occurs that is an alteration of the normal histologic structure of the cartilage framework of the ear.
Histologic changes account for the appearance changes noted during after an auricular hematoma. Usually, the ear is made of elastic cartilage. Secondary to trauma, the normal cartilage structure changes in a studied fashion. At two weeks of an auricular hematoma, cartilage formation occurs on either side of the hematoma. By three weeks, the hematoma is replaced by soft tissue. By eight weeks, the soft tissue is replaced by cartilage. At fourteen weeks, bony formation, calcification, and further cartilage growth occur. These histologic changes account for the change in the external appearance of the ear.
Always start with open-ended questions and progress through a standard history. Special questions to note are recent trauma, pain/tenderness of ear, previous occurrences, fevers/chills, drainage from ears, change in hearing, immunosuppression, diabetes, blood-thinning medications, and hypertension. Physical exam involves a thorough evaluation of external ear with knowledge of baseline anatomy to differentiate the pathology. Use of an otoscope to evaluate the external ear canal and tympanic membrane is paramount. A recent history of trauma is common, and wrestling and boxing are common risk factors. If the mechanism of trauma is large, such as a motor vehicle accident, the practitioner must rule out temporal bone trauma.
A proper exam would include a full head and neck exam, with the details of this being beyond the scope of this article. A focused physical exam includes an evaluation of the external ear, evaluation of the tympanic membrane with an otoscope, and evaluation for any coexistent lacerations or trauma of the head and neck. It is imperative to evaluate for facial nerve weakness as this structure passes through the ear and can be damaged if ear trauma is sustained. Physical exam findings consistent with auricular hematoma include contour irregularity of ear with swelling and fluctuant area overlying the ear's cartilaginous portions. Likely symptoms include pain, paresthesia, and ecchymosis.
Diagnosis of an auricular hematoma is typically preceded by a detailed history and physical; this will achieve a diagnosis of an auricular hematoma. Ultrasound can be utilized to evaluate ear swelling and rule out an auricular abscess. The practitioner may use CT/MRI if significant trauma occurred, if there is a concern of a foreign body or an abscess formation, or to delineate the middle or inner ear structures; however, this should not be used routinely.
If there is evidence of erythema, warmth to the area, diffuse pain on palpation of cartilage, evidence of external auditory canal swelling, or drainage, then the diagnosis of auricular hematoma is less likely. Typically, hearing is not affected by this disease, and if the patient has a subjective hearing loss, then expanding the differential is necessary. In summary, clinical diagnosis is all that is required.
Patients can be safely managed outpatient for this medical disease, whether presenting to ED, primary care, or urgent care facility. Consultation and/or referral to otolaryngology or plastic surgery is recommended. A detailed history and physical is adequate for diagnosis.
Once a hematoma is diagnosed, treatment may take place at the bedside or in the operating room and involves a linear incision overlying the swelling or hematoma formation with a subsequent evacuation. The goal of an incision is to drain the fluid collection; however, keep in mind that making the incision in a cosmetically appealing site is ideal. Areas of concavity will heal with a more aesthetically pleasing result than areas of convexity.
The first step is determining whether operating room or bedside hematoma evacuation is appropriate. Discussing the risks, benefits, and alternatives to treatment is recommended to determine the best setting. Keep in mind that patients can opt for no treatment which is acceptable as long as they know the risks this may pose. If the hematoma occurred in an acute setting < 48 hours, an attempt at drainage is appropriate. Once the appropriate setting is determined, the first step is proper setup and gathering of necessary equipment. Patients should be placed supine with the head of the bed propped up and the head turned contralateral in relation to the side of the auricular hematoma for adequate exposure. Ensure proper lighting. Supplies should consist of an 11 blade or 15 blade knife and/or an 18-gauge needle with a 10 cc syringe, suction canister, tubing and suctioning instrument (Frasier), a hemostat, toothed forceps, suture supplies with scissors, bolster material, local anesthetic, and local skin cleansing material. After the patient is positioned properly, the ear is cleaned with a form of local cleansing agent such as povidone-iodine. At this point, local anesthesia should be injected or applied topically (e.g., lidocaine, bupivacaine, LET gel). This can be performed in an auricular block pattern or directly into the site of the auricular hematoma. At this time, hand hygiene, application of gloves (sterile), gowning (optional), headlight (optional), and or Loupes (optional) should be performed. After several minutes, the anesthesia should have taken effect, and the practitioner can grab the tissue of the planned incision with toothed forceps to determine if the area is numb. If adequate anesthesia has occurred, use a scalpel or 18-gauge needle to evacuate the hematoma. Some studies suggest an 18-gauge needle may be acceptable in an auricular hematoma under 2 cm. If an 18 gauge needle is used, jump to the application of a bolster after complete removal of hematoma. If incision with a knife is used, evacuation of the hematoma should occur with a hemostat and suction instrumentation. Once all the hematoma is removed, the site can be irrigated with normal saline. At this time, bolster dressing should be applied to close the dead space or potential space where the hematoma formed. If using dental rolls, two dental rolls should be used to run parallel with the incision line on either side of the ear. Two vertical mattress sutures should be placed through the dental rolls to secure the bolster. A permanent suture material such as nylon is appropriate. The suture is ideally on a Keith Needle; however, this is not mandatory. Adequate bolster is applied when there is no potential space for accumulation of hematoma; however, it is loose enough to preserve the vascular supply of the ear. At this time, the application of bacitracin to the incision site is appropriate. It is important to remove all instruments and dispose of sharps appropriately once the procedure is deemed complete. Proper wound care instructions, followup, and disposition should be explained to the patient and/or family.
There are several variances in the type of bolster used, however, the goal is the same: eliminate the potential space for fluid to accumulate. Newer strategies include the use of splinting material that can be molded to the ear. A recent case reports using fibrin glue to secure the perichondrium to the cartilage to reduce the risk of separation. Bolster dressing can be removed after 5 to 7 days. Antibiotic use is left to the discretion of the physician. If cauliflower ear does form, excision with repair may be undertaken in the form of otoplasty; however, this will require referral to ENT or plastic surgery.
The differential diagnosis in distinguishing auricular hematoma is necessary to provide appropriate treatment and follow-up. It is important to rule out infectious, autoimmune, and traumatic sources of auricular swelling. The most common differential diagnosis should include auricular hematoma, perichondritis, auricular abscess, cellulitis, Winkler disease (relapsing perichondritis), a temporomandibular disorder resulting in external ear pain, laceration, normal anatomic variance, erysipelas, sunburn, and skin cancer.
The complications of an auricular hematoma are cosmetic, re-accumulation of blood after drainage, infection, discomfort, and paresthesia. The typical cauliflower ear deformity is infamous for forming after untreated or repeated auricular hematomas. The typical appearance of a cauliflower ear is a misfolded ear with several soft tissue humps abnormally located in the ear, overlying where normal cartilage would be found. If the auricular hematoma is drained, there is a risk of infection, pain, discomfort, allergy or anaphylaxis to anesthesia or local anesthetic, unsightly scar formation, and re-accumulation. The risks are minimal; however, they do occur and must be conveyed to the patient for adequate consent to the procedure with a procedure. Always discuss the risks, benefits, and alternatives to management and provide adequate follow up to ensure patient follow-up with ENT or plastic surgery.
Patients are instructed to take antibiotics if prescribed, pain medications as prescribed, followup as directed, limited physical activity for 10 to 14 days, avoidance of contact sports for 1 to 2 weeks. If a splint is used, this will need to be removed in 5 to 7 days. Antibiotics can be given while the splint is in place.
Appropriate referrals/consultations are to otolaryngology as they can diagnose, treat, and rule out associated external, middle, or inner ear pathology. Plastic surgeons can evaluate and treat an auricular hematoma.
After resolution of the acute auricular hematoma, proper patient education is paramount to reducing the risk of this reoccurrence. Directing the patient to reduce the risks for trauma is imperative; this can be in the form of decreased physical activities that may place the patient at risk of this disease process. This is often the most difficult portion of the encounter as patients are usually involved in contact sports and unwilling to abstain from these sports for an adequate time period. Other factors that may predispose to auricular hematoma formation is substance abuse, seizure disorder, physical debility, or abuse from a caregiver or partner. With athletes, it should be stressed to wear appropriate head protection to limit the changes of recurrent auricular hematomas. In the acute setting, the use of ice to the area is beneficial in intervals of 15 to 20 minutes. Patients should take medication as prescribed by the practitioner.
An auricular hematoma is a manifestation of trauma to the ear that can present to multiple specialties. Appropriate diagnosis and/or referral to otolaryngology or plastic surgery is imperative to prevent the dreaded cauliflower ear. A basic understanding of the ear paired with a history that suggests recent trauma is needed for the correct diagnosis for an auricular hematoma. In the situation where a diagnosis is difficult, a low threshold to contact/refer a patient to otolaryngology or plastic surgery should be undertaken. This is important because if an auricular hematoma is mistaken for an external ear infection in a diabetic or immunocompromised individual the consequences can be deadly. A thorough ear exam is imperative to complete a full evaluation of an auricular hematoma and rule out damage to other structures of the ear. Appropriate management will improve patient cosmesis and decrease the chances of the patient requiring a more invasive procedure, such as otoplasty, in the future. Referral to otolaryngology or plastic surgery should be an established plan of care with auricular hematomas. (Level III)