Cauliflower ear is a deformation of the ear typically caused by direct trauma to the auricula and surrounding tissue. Classically, experienced by wrestlers or boxers, the condition is caused by direct, blunt trauma where significant shearing forces lead to an auricular hematoma. The hematoma then disrupts the blood supply to auricular perichondrium and subsequently the ear’s cartilage. As a result, blood accumulates in the subperichondrial space and if left untreated can lead to necrosis, infection, and loss of cartilage. Cauliflower ear is the product of the fibrocartilage and fibrosis that occurs upon the destruction of the ears healthy cartilage once it loses its blood supply.
Description of cauliflower ear dates back to early Roman and Greek history. Literary and artistic collections from that time are littered with accounts describing the deformed or damaged ears of wrestlers, boxers, or pugilists. Medical appreciation for the affliction has a similar storied past. Though case descriptions can be found in the works of Hippocrates, more formal research into the disease did not begin until the mid-1800s. At that time, there was thought to be a second idiopathic cause behind cauliflower ear to go along with the more obvious relationship to direct trauma. The idiopathic hypothesis derived from observations of the elderly and mentally insane. It wasn’t until the late 20th century that the more conventional understanding of cauliflower developed.
The exact prevalence of cauliflower ear is not noted in the literature. From studies conducted on wrestlers, researchers approximated that between 39-45% of athletes were affected with cauliflower ear.
Historically, researchers have debated the exact mechanism behind the formation of cauliflower ear. From a series of experiments conducted in the mid-1970s when weights were dropped on the ears of rabbits, researchers concluded hematomas in the intercartilaginous space were responsible for the deformity. However, further testing (and more rabbits), showed blood accumulation in the subperichondrial space was responsible for disrupting circulation to the anterior ear from the posterior auricular and superficial temporal arteries. This buildup leads to the necrosis of the ear’s healthy cartilage. The hematoma is then replaced by chondroblasts which began to form neocartilage. This process sets into action a cascade of fibrosis and contracture and the subsequent development of cauliflower ear.
Patients present as having undergone some trauma to the affected ear, usually during contact sports like wrestling, boxing, or increasingly, mixed martial arts. The ear appears red, swollen, and warm, while the patient may describe any combination of difficulty hearing, tinnitus, vision changes, pain, and/or a headache. If there is no concern for more underlying severe cranial pathology, then the practitioner should continue directly to treatment.
The strong relationship between trauma causing auricular hematomas should make practitioners suspicious of those individuals presenting with the signs described above, but who deny having undergone any reported trauma. Especially where children and the elderly are concerned, it is crucial that the possibility of abuse be entertained and screened for through careful history and exam.
Cauliflower ear is a clinical diagnosis that requires no formal testing or imaging.
The management and treatment of cauliflower ear can take many forms depending on when the patient presents and the size and scope of the deformity. It should be noted from the outset, that cauliflower ear is potentially avoidable through the appropriate covering and protection of the ear during contact sports. This protection reduces or eliminates the types of blunt, shearing forces the ear experiences altogether and subsequently, the formation of an underlying hematoma. According to studies of wrestlers, the use of protective headgear can reduce the prevalence of auricular hematomas by up to 50%.
Any trauma to the head severe enough to injure the exterior ear mandates a thorough head and neck examination that includes the otoscopic inspection of the tympanic membranes. This exam ensures a more critical intracranial injury is not overlooked.
The primary treatment for cauliflower ear is prevention. The best possible outcomes require early identification and management of the hematoma before cartilage death has occurred. Typically this requires a patient be seen within the first six hours of injury so that an emergency department provider can aspirate the underlying auricular hematoma. This involves anesthetizing the distribution of the greater auricular nerve using lidocaine and epinephrine. This is followed by insertion of an 18-gauge needle into the area of greatest fluctuance. If the patient is unfortunate enough to present outside the 6-hour period where aspiration is likely to be successful, a more invasive incision is required to be sure to remove free blood, but also blood that has begun to coagulate.
By removing the pocket of blood, the perichondrium can reattach to the ear’s cartilage, preventing the loss of its valuable blood supply. Further aiding in the ear’s development of healthy cartilage, is the use of compressive dressings. A variety of compressive dressings are described in the literature including cotton bolsters, dental silicone, silicone rubber splints or even auricular stents, but no one technique has been studied and deemed superior.
Unfortunately, recurrence remains a frustrating complication of treating cauliflower ear. The most successful management of an auricular hematoma comes with the high likelihood that the blood will re-accumulate. For this reason, it’s important that outpatient providers refer patients to an otolaryngologist, an ear, nose, and throat (ENT) specialist for ongoing care and treatment.
For patients who present outside the window when auricular hematoma drainage is feasible, surgical intervention remains the mainstay of treatment. In general, a surgical referral is appropriate for any patient with an existing cauliflower ear, where extensive fibrosis has already occurred. Once the surgery is settled upon, the exact approach can vary based on the degree and location of the underlying deformity. Some texts go so far as to classify cauliflower ear into four distinct types, each requiring a unique reconstructive technique. The overall goal of surgery, however, remains the same regardless of surgical method, and that is to remove the damaging fibrocartilage without compromising the ear's structural integrity or its natural contours. If damage to the ear is so severe that simply removing the malformed cartilage does not equate to the desired cosmetic outcome, costal cartilage can be used to provide greater structural integrity.