Auricular Hematoma

Aka: Auricular Hematoma, Pinna Hematoma, Aural Hematoma, Ear Hematoma, Cauliflower Ear, Auricular Bolster, Auricular Compression Dressing

1. Pathophysiology
   1. Repeated auricle blunt and shearing Trauma (although some cases may be spontaneous)
   2. Perichondrium separates from cartilage
      1. Allows blood to accumulate around cartilage (subperichondrial space)
      2. Results in interruption of cartilage perfusion with risk of necrosis and permanent deformity
2. Risk Factors: Sports Injury
   1. Wrestling
   2. Boxing
   3. Polo
   4. Water
   5. Rugby
3. Signs
   1. Fluctuant bluish swelling of anterior superior auricle
4. Management: Decompression
   1. Patient positioned in lateral decubitus position with affected ear up
   2. Prepare the skin with Betadine, Hibiclens or chloraPrep
   3. Anesthetize the auricle with Ear Field Block (auricular block) or Local injection
      1. Lidocaine 1% in 10 ml syringe and 27 gauge needle
   4. Perform with sterile technique to prevent infection (perichondritis)
   5. Drainage
      1. Needle aspiration with 18 gauge or larger needle (greater risk of reaccumulation) OR
      2. Incision (1-2 cm superficial incision) and drainage (preferred)
         1. Use Scalpel #15 to make a 1-2 cm incision at the base of the hematoma, following skin folds
         2. Use suction or express the hematoma manually
         3. Consider saline irrigation of the hematoma
         4. Reapproximate the perichondrium and cartilage
         5. Suture incision with 4-0 Vicryl
   6. Apply Auricular Bolster (compression dressing)
      1. See below
      2. Prevents reaccumulation
5. Management: Auricular Bolster (compression dressing)
   1. Indications
      1. Auricular Hematoma
      2. Auricular Laceration (consider)
   2. Preparation
      1. Ear Anesthesia (see Ear Field Block)
      2. Skin Preparation (e.g. Betadine or Hibiclens)
      3. Nylon Suture (e.g. Ethilon) 3-0 or 4-0
      4. Material for 2 Bolsters (choose one)
         1. Dental rolls
         2. Folded 2x2 gauze
         3. Rolled Xeroform gauze (e.g. adaptic)
         4. Cotton
         5. Silicone Splint
         6. Plastic Bolster
      5. Lubricant
         1. Bacitracin or Xeroform gauze applied to surface of bolster to keep from adhering
   3. Technique
      1. Sandwich auricle between two bolsters
      2. Suture through the first bolster, auricle, and second bolster and tie
      3. Repeat suturing at a second location along the bolster
      4. Apply additional compressive dressing over the top of the ear and wrapped around the head
   4. Resources
      1. Brown EM Residency Video
         1. https://www.youtube.com/watch?v=sIlm7vPs3q8
6. Management: General
   1. Other measures
      1. Many ENTs will start Augmentin while treating Auricular Hematoma
         1. Consider antibiotics in higher risk patients (e.g. Immunocompromised)
      2. Update Tetanus Vaccine status
      3. Wear protective ear equipment to prevent reinjury
      4. Avoid antiplatelet agents and Anticoagulants if possible during the healing process
   2. Follow-up
      1. Re-evaluation in 18-24 hours to exclude reaccumulation (and need for repeat hematoma drainage)
      2. Consider repeat evaluation daily for first 3-5 days
   3. Otolaryngology Consultation Indications
      1. Auricular Hematoma presentation at >7 days from onset
7. Complications: Auricular Hematoma
   1. Cauliflower Ear
      1. Irreversible External Ear deformity from inadequately drained clot and fibrous deposition
8. Complications: Incision and Drainage
   1. Perichondritis
      1. Pseudomonas aeruginosa
      2. Staphylococcus aureus
   2. Scar
   3. Failed drainage
   4. Recurrent Auricular Hematoma
9. References
   1. Claudius, LoTempio, Behar and Swaminathan in Herbert (2016) EM:Rap 16(8): 2-3
   2. Dreis (2020) Crit Dec Emerg Med 34(7):3-219
   3. Kotipoyina and Warrington (2018) Crit Dec Emerg Med 32(5): 18