High Yield Topics

Auricular Hematomas

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Ovid: 5-Minute Sports Medicine Consult, The


Auricular Hematomas
Kevin E. Elder
Todd Toriscelli
Basics
Alert
Failure to diagnose and promptly treat this condition with evacuation of the hematoma may lead to permanent deformation of the ear.
Description
  • Auricular hematoma is an injury caused by trauma or friction of the ear that often occurs in contact sports such as rugby, wresting, boxing, and judo.
  • Trauma or continuous friction to the auricle leads to bleeding into the soft tissues of the ear.
  • Bleeding often occurs anteriorly at the junction of the perichondrium and elastic cartilage of the ear.
  • Recognition of this condition as a result of trauma led to the development of treatments during the latter half of the 20th century.
Epidemiology
Incidence
  • The incidence of this condition is higher in young males owing to their predilection to participate in the sports most often producing this injury. One study of collegiate wrestlers found a statistically significant difference in wrestlers developing auricular hematoma while wearing headgear (26%) versus those who were not wearing headgear (52%) (1).
  • This is a reported 50% decrease in incidence of the condition in wrestlers who consistently wore protective headgear during training and competition (1).
Prevalence
  • This condition is more prevalent in young males because they are most often the participants in the specific organized team sports associated with the injury, but it may occur in males or females.
  • There are no well-established records of the exact prevalence of this condition.
Risk Factors
Failure to wear headgear while participating in sports such as wresting, rugby, or martial arts disciplines such as judo may increase the risk of ear trauma.
General Prevention
  • General prevention is based on proper use of headgear during participation.
  • Ill-fitting headgear may provide inadequate protection to the auricle.
  • Awareness of the importance and use of proper fitting headgear by athletes, coaches, and athletic training staff may prevent this injury.
Etiology
  • The condition is caused by trauma owing to a direct blow or frictional forces to the auricle.
  • Bleeding into the auricle, specifically between the skin and auricular cartilage, results in a hematoma in this space.
  • Untreated, the hematoma can cause pressure, necrosis, and scarring of the auricular cartilage leading to a “cauliflower ear,” which is the name given to the characteristic deformity to the ear.
    • Neocartilage formation at the site of the clot also plays a role in the associated deformity.
    • This deformity is disfiguring and permanent.
Commonly Associated Conditions
  • Auricle laceration
  • Rupture of tympanic membrane owing to associated trauma
  • Concussions related to head trauma
  • Cellulitis and perichondritis may mimic or be associated with this disorder.
Diagnosis
  • Diagnosis is made based on clinical exam and history of trauma/excessive friction to the ear (2)[C].
  • The absence of associated factors that may lead to cellulitis of the ear may aid in the correct diagnosis.
History
  • History of direct and recent trauma to the auricle with resulting hematoma
  • Lack of protective head gear while participating in high-risk sports for this injury should raise level of suspicion.
  • The athlete complains of a painful ear and may have associated hearing loss.
Physical Exam
  • Examination of the auricle reveals a soft hematoma with tenderness of the auricle presenting within a few hours after the inciting injury.
  • Loss of the normal architecture of the auricle compared with the contralateral side
  • Exam should include an assessment of the athlete's hearing.
  • Associated ear drainage should prompt consideration for rupture of the tympanic membrane.
  • Assessment to rule out signs and symptoms of concussion should be performed.
Diagnostic Tests & Interpretation
Diagnosis of this condition is based on history and clinical exam.
Lab
  • No specific lab tests confirm diagnosis.
  • CBC or ESR may aid in the diagnosis of associated infection.
Differential Diagnosis
  • Ear laceration
  • Cellulitis of ear
  • Perichondritis
Treatment
  • Once frictional and/or direct pressures have resulted in a hematoma between the skin and auricular cartilage, the initial goal in treatment is to aspirate this area to prevent further complications.
  • Following anesthesia with lidocaine without epinephrine, aspiration can be attempted with a 25-gauge needle and syringe (2)[C].
    • This aspiration must be done in the acute phase when the hematoma is palpable.
    • Later evacuation of the hematoma may require an 18–22-gauge needle (3)[C].
  • If left untreated, the hematoma can lead to neocartilage formation, scarring, and necrosis, all of which can lead to permanent deformity.
  • Antibiotics are sometimes given as a preventative measure because infection of the auricle will result in further poor outcomes. Antibiotics should cover common skin bacteria. Cephalexin is used commonly.
  • To prevent reaccumulation of the hematoma and the need for additional aspirations, a compression dressing must be applied to the area.
  • Incision and drainage followed by mattress suture placement also have been described. This method is more time- and labor-intensive but allows for better cosmetic results.
Medication
  • Consider antibiotics for prophylactic coverage (eg, cephalexin ×7 days). If suturing or incision and drainage are done, antibiotics definitely should be used (4)[C].
  • NSAIDs and aspirin should be avoided to minimize hematoma recurrence risk.

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Additional Treatment
  • The importance of acute aspiration of hematoma has been described, as well as the possible need for attempted hematoma evacuation with a larger-bore needle.
  • On occasion, a pressure dressing may not be needed if the hematoma does not recur within 1 hr of successful aspiration (5).
  • To prevent reaccumulation of the hematoma and the need for additional aspirations, a compression dressing commonly is placed over the area.
    • Compression must stay over the ear until it is fully healed.
    • Compression dressing may be needed for 3 days or more.
  • Owing to the shape of the ear, firm and even compression can be challenging. The most widely used method of compression is the application of a collodion cast dressing (6)[C].
    • This is accomplished by mixing collodion, a topical adhesive, with sterile gauze. The resulting adhesive cast then is formed around the auricle. The cast hardens in a short period of time and, if performed properly, can result in uniform compression (7)[C].
    • Another treatment involves a mold of the ear being taken and a compression cast made from silicone of the mold (8)[C].
    • Another method that may provide to be the best uniform compression but is more time- and labor-intensive is through-and-through mattress sutures (9)[C].
      • These maintain pressure, sometimes with use of dental rolls or a button.
      • A small incision is made along the helical or anthelical rim for hematoma evacuation, and sutures are placed afterward (3)[C].
      • The ear's natural contour is maintained.
      • This method is more technically difficult and may more appropriate for ENT or plastic surgery.
      • These type of sutures may remain for up to 7–10 days.
Surgery/Other Procedures
The possibility of surgery may be entertained, as mentioned earlier, in consultation with ENT or plastic surgery.
Ongoing Care
Follow-Up Recommendations
Daily follow-up is needed to observe for signs of hematoma redevelopment, pressure necrosis, allergic reaction to materials, and infection.
Patient Monitoring
Follow-up with ENT or plastic surgery after acute treatment is recommended because of the risk of poor cosmetic result even with proper treatment of the condition.
Patient Education
  • Return to play too early, prior to fully healing of the injury, will increase the risk of a poor outcome.
    • No definitive return-to-play protocol exists.
    • Some authors recommend no competition while wearing ear compression dressing, whereas others allow full activity with ear protection being worn (10).
    • The decision should be made in consultation with the athlete, recognizing the potential for poor cosmesis with recurrence of the injury.
  • Ear protectors and headgear always should be worn in high-risk sports.
  • Ice and pressure applied at the end of practices and matches may help to prevent recurrence of injury.
Prognosis
  • Best prognosis is achieved by prompt aspiration and compression if needed.
  • Poorer outcomes are associated with repeated need for aspiration and earlier return to contact sports/reinjury.
Complications
  • Permanent scarring and cosmetic deformity.
  • Chondritis and perichondritis.
  • Prompt treatment including aseptic technique may prevent these consequences.
References
1. Schuller DE, et al. Auricular injury and the use of headgear in wrestlers. Arch Otolaryngol Head Neck Surg. 1989;115:714–717.
2. Mudry A, Pirsig W. Auricular hematoma and cauliflower deformation of the ear: from art to medicine. Otol Neurotol. 2009;30:116–120.
3. Wu TS. Tricks of the trade: head and neck procedures. American College of Emergency Physicians Scientific Assembly, 2008.
4. Sallis RE, Massimino F. ACSM's Essentials of Sports Medicine. General Medicine. Mosby, 1997:120–121.
5. Davidson TM, Neuman TR. Managing ear trauma. Phys Sports Med. 1994;22(7):27–32.
6. Inside Surgery.com. Treatment of hematoma of the auricle. July 16, 2009.
7. Macdonald DJ, Calder N, Perrett G, et al. Case presentation: a novel way of treating acute cauliflower ear in a professional rugby player. Br J Sports Med. 2005;39:e29.
8. Lane SE, Rhame GL, Wroble RL: A silicon splint for auricular hematoma. Phys Sports Med. 1998;26:9.
9. Giles WC, Iverson KC, King JD, et al. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007;117:2097–2099.
10. Schuller DE, Dankle SD, Strauss RH: A technique to treat wrestler's auricular hematoma without interrupting training or competition. Arch Otolaryngol Head Neck Surg. 1989;115:202–206.
Additional Reading
Dallas B: Cauliflower ear: the trademark worn by a competitive wrestler. ACC.com; Wrestling. Dec 2004.
Kaufman BR, Heckler FR: Sports related facial injuries. Clinics Sports Med. 1997;16(3):543–562.
Mellion et al, eds. Team Physician's Handbook, 3rd ed. Wrestling, 617. Hanley & Belfus, 2002.
Codes
ICD9
380.31 Hematoma of auricle or pinna
Clinical Pearls
  • Diagnosis of this condition is based on history and clinical exam.
  • Early recognition and treatment of this condition with hematoma aspiration may prevent long-term sequelae and disfigurement.
  • Return to contact sports without sufficient time for injury to fully heal/allow adequate retreatment increases the risk for a poor cosmetic result.
  • Compression treatment options include collodion cast, silicon cast, and horizontal mattress suture repair.
  • ENT/plastic surgery consultation may be required.
  • Use of ear protection/headgear is effective in prevention of this condition.


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