Chapter 168. Auricular Hematoma Evacuation

Blunt trauma to the auricle can cause abrasions, ecchymosis, hematoma formation, and lacerations. Abrasions and ecchymosis of the auricle require no therapy other than oral analgesics and observation for infection.1 Some authors recommend the application of topical antibiotics to all abrasions as prophylaxis for infection.2 Lacerations to the auricle are addressed in Chapter 96. This chapter addresses the management of an auricular hematoma.

Injuries to the auricle are common due to its exposed position and lack of protection from surrounding structures.3 The most common cause for an auricular hematoma formation is blunt trauma while participating in the contact sports of wrestling or boxing.1,2,4–6 Such trauma may occur in other situations, including assaults, falls, fights, and motor vehicle crashes. Auricular trauma and hematomas are common in children due to the high incidence of head injuries during playtime.2,4 Blood dyscrasias may also cause an auricular hematoma.

An auricular hematoma presents as a firm and painful swelling that obscures the normal convolutions on the lateral aspect of the auricle. It can develop within minutes to hours of the blunt trauma. An auricular hematoma must be evacuated to prevent the cosmetic disfigurement known as cauliflower ear. The sooner it is evacuated, the less chance of permanent disfigurement.4,5 After evacuation, the patient requires a pressure dressing to the auricle, oral antibiotics, and close follow-up to prevent complications.2,5,7,8

The auricle is that portion of the external ear that projects from the side of the head. It functions to augment sound delivery to the tympanic membrane and assist in sound localization. It is fixed in position by both ligaments and muscles.9 It has an underlying cartilaginous framework that is 0.5 to 1.0 mm thick and provides the auricle with its unique shape. The cartilage is a single, thin sheet of flexible yellow elastic cartilage with many convolutions on the lateral surface.10 The only portion of the auricle without cartilage is the lobule in which fibrofatty tissue replaces the cartilage.9 The cartilage is avascular and derives its blood supply and nutrients from the adjacent perichondrium.11

The skin covering the auricle is similar to that elsewhere on the body.12 It contains sebaceous glands and a varying number of hair follicles. The skin on the lateral surface of the auricle is tightly adherent to the perichondrium and lacks a subcutaneous layer (Figure 168-1). The skin on the medial surface of the auricle is loosely attached and has a layer of subcuticular tissue between the skin and perichondrium.

Trauma may cause the perichondrium to be torn off the underlying cartilage due to the tight attachment of the skin to the perichondrium on the lateral surface of the auricle. This traumatic avulsion of the perichondrium causes hemorrhage into the space between it and the cartilage, allowing a hematoma to form (Figure 168-2). Bleeding into this potential subperichondral space causes dissection of the perichondrium from the underlying cartilage. Auricular hematomas can be painful due to the rich sensory innervation to the area and the accumulation of blood in this relatively closed space.11 Failure to adequately evacuate a hematoma may lead to cartilage necrosis and a deformed ear. The necrosis is due to a combination of separating the cartilage from its blood supply and direct pressure effects from the hematoma.

The cauliflower ear is a purely cosmetic deformity that results from an auricular hematoma not being evacuated and allowing the auricle to spontaneously heal. The hematoma is invaded by fibroblasts and slowly replaced by fibrous tissue. This organization of the hematoma causes irregular thickening of the auricle. The perichondrium, elevated from the cartilage by the hematoma, senses the lack of adjacent cartilage and activates chondroblasts. New cartilage is deposited on the surface of the hematoma causing further thickening and deformity of the auricle.

Innervation of the Auricle

A brief review of the innervation of the auricle will later aid in understanding the technique of regional anesthesia. Three nerves contribute to the sensory enervation of the auricle (Figure 168-3).8,11–15 The auriculotemporal branch of the mandibular division of the trigeminal nerve supplies sensation to the upper, lateral surface of the auricle. This nerve emerges subcutaneously just anterior to the auricle at the level of the external auditory canal. Two branches of the cervical plexus become subcutaneous at the posterior border of the midportion of the sternocleidomastoid muscle and ascend to the auricle. The lesser occipital nerve provides sensory innervation to the upper medial surface of the auricle. The great auricular nerve provides sensory innervation to most of the medial surface and the lower half of the lateral auricular surface.

An auricular hematoma must be evacuated. The indication for evacuation is to prevent the cosmetic deformity known as the cauliflower ear.7 It is preferable to evacuate the hematoma within 12 to 24 hours after its occurrence. Although there is no urgency to immediately evacuate the hematoma, the longer it remains the higher the chance of clot organization and new cartilage deposition.7,16

There are no absolute contraindications to the evacuation of an auricular hematoma. If the skin overlying the hematoma is cellulitic, or if purulent material is drained from the hematoma, the patient will require hospital admission and intravenous antibiotics.1,8 An Otolaryngologist or Plastic Surgeon should be immediately consulted on these patients. The auricular hematoma should be evacuated by a consultant if it has been present for more than 5 to 7 days. These hematomas have already begun organization and new cartilage has developed requiring curettage associated with the evacuation.7,16,21,23 An uncooperative patient (e.g., young child or due to altered mental status) may require evacuation under procedural sedation or in the operating room.

Auricular Anesthesia

• Povidone iodine or chlorhexidine solution
• 1 mL syringe
• 10 mL syringe
• 25 to 30 gauge needles, 2 inches long
• 10 to 20 mL of local anesthetic solution without epinephrine

Auricular Hematoma Aspiration

• Povidone iodine or chlorhexidine solution
• Tuberculin or insulin syringe
• 0.25 mL of local anesthetic solution without epinephrine
• 10 mL syringe
• 18 gauge needle
• Topical antibiotic ointment

Auricular Hematoma Incision and Drainage

• Auricular anesthesia as above
• #15 surgical scalpel blade on a handle
• Curved hemostat
• Sterile drain (optional)
• 10 mL syringe
• 18 gauge angiocatheter without the needle
• Sterile saline
• Topical antibiotic ointment
• Forceps

Mastoid Pressure Dressing

• Petrolatum gauze
• Cotton balls soaked in sterile saline
• Dry cotton balls
• 4 × 4 gauze squares
• 4 inch elastic bandage
• Scissors

Surgical Pressure Dressing

• Cotton bolsters or dental rolls
• Needle driver
• 4-0 monofilament nylon suture

Explain the risks, benefits, and potential complications of the procedure to the patient and/or their representative. The postprocedural care should also be discussed. Obtain a signed consent for the procedure. Some Emergency Physicians omit the signed consent and place the following statement in the procedure note: “The risks, benefits, and complications were described and discussed with the patient. They understood this and gave verbal consent for the procedure.” This decision must be based on physician preference, hospital guidelines, and state guidelines for documentation requirements.

Remove any dirt and debris from the auricle and surrounding skin. Apply povidone iodine or chlorhexidine solution to the same areas. Follow aseptic technique for the remainder of the procedure.4 In patients who are anxious and without other associated injuries, the administration of intramuscular, intravenous, or oral benzodiazepines may be beneficial.15

Auricular Anesthesia

The local anesthetic solution used for auricular anesthesia should contain no epinephrine.2,13,14,17 Epinephrine is not used for fear of intense vasoconstriction of end arterioles resulting in decreased perfusion with possible ischemia and necrosis of the auricle. Some authors recommend the use of 1/100,000 epinephrine mixed with the local anesthetic solution.1,15,16 The epinephrine may decrease bleeding by its vasoconstrictive action. It may also prevent reaccumulation of the hematoma after it has been evacuated. Authors who advocate using epinephrine state that the auricle has a rich blood supply and that, based on anecdotal evidence, there is no danger of ischemia or necrosis from the use of epinephrine in healthy patients without evidence of traumatized vascularity. Although many physicians will use epinephrine, it has not been proven safe to use or proven to prevent reaccumulation of the hematoma. It may be wiser to be conservative and not use epinephrine than to use it and have to deal with the complications to the patient and potential litigation.

The choice of which local anesthetic to use is physician-dependent. Lidocaine (1%) is the most commonly used local anesthetic. Long-acting local anesthetic solutions, such as bupivacaine (Marcaine) or etidocaine (Duranest), may be used to provide analgesia for several hours after the procedure is completed.14

The methods of anesthesia for evacuation of an auricular hematoma range from none to a superficial skin wheal to a regional block. Some authors advocate using no anesthesia if needle aspiration of a small and fresh hematoma is performed.2 This is not generally recommended as the pain from an 18 gauge needle aspiration is more uncomfortable than local anesthesia infiltration.

If using the aspiration technique to evacuate the hematoma, local anesthetic solution can be infiltrated directly over the hematoma. Apply a 25 to 30 gauge needle on a 1 mL syringe. Place a skin wheal, using 0.25 mL of local anesthetic solution without epinephrine, over the hematoma in the area of maximum fluctuance. When placing the skin wheal, be careful not to inject the local anesthetic solution into the hematoma. This will cause expansion of the hematoma and increase the separation of the perichondrium from the underlying cartilage.17 It may also cause new bleeding, which can increase the possibility of hematoma reaccumulation.

A regional auricular block is the preferred method to obtain anesthesia.13 It prevents distortion of the auricle from direct injection and further separation of the perichondrium from the underlying auricular cartilage.17 Subcutaneous infiltration of the surrounding skin is less painful than injection directly into the sensitive auricular skin.15 The landmarks for regional anesthesia are simple to locate, consistent, and predictable. The greatest reason for failure of an auricular block is incorrect needle placement.14 A regional auricular block can be done prior to using the aspiration technique or the incision and drainage technique to evacuate the hematoma. If the aspiration technique fails (i.e., hematoma reaccumulates), then there is no need to reprep and perform an auricular block prior to performing the incision and drainage.

There are three methods to perform a regional auricular block (Figures 168-4 & 168-5). Each method blocks the lesser occipital, great auricular, and auriculotemporal nerves. Some Emergency Physicians prefer to subcutaneously inject local anesthetic solution circumferentially around the attachment of the auricle to the head (Figure 168-4).2,11,13,17 An alternative method is based on blocking the sensory supply to the ear in a more anatomic distribution (Figure 168-5).8,14 This latter method uses half the anesthetic and half the number of subcutaneous injections than the former method. For these reasons, this author prefers the second method, which is described in the following paragraph.

To perform a regional auricular block, first cleanse the auricle and surrounding skin of any dirt and debris. Apply povidone iodine or chlorhexidine solution. Place a skin wheal of local anesthetic solution 0.5 cm below the pinna of the auricle (Figure 168-5A). Insert a 2 inch, 25 or 27 gauge needle through the skin wheal, aimed just posterior to the attachment of the auricle to the head. Infiltrate subcutaneously, in a superior direction, always remaining 0.5 to 1.0 cm posterior to the auricular attachment to the head. Stop infiltrating at the level of the superior attachment of the auricle to the head. This infiltration requires 4 to 7 mL of local anesthetic solution. Withdraw the needle almost completely. Redirect the needle through the skin wheal and aimed just anterior to the attachment of the auricle to the head. Infiltrate subcutaneously, in a superior direction, always remaining 0.5 to 1.0 cm anterior to the auricular attachment to the head. Stop infiltrating at the level of the superior attachment of the auricle to the head. This infiltration also requires 4 to 7 mL of local anesthetic solution. Care must be taken not to inject too deeply anterior to the auricle as it can cause temporary paralysis of the facial nerve. An alternative to the anterior infiltration is the injection of 3 to 4 mL of local anesthetic solution just superior and anterior to the tragus (Figure 168-5B).1,18 This injection blocks the auriculotemporal nerve at its origin. Allow 10 to 15 minutes for the full anesthetic effect prior to beginning the procedure.17

The methods for treating and managing an auricular hematoma require the evacuation of the hematoma and replacing the perichondrium onto the underlying cartilage. The techniques include aspiration, incision and drainage, and closed suction drainage. The first two techniques will be described in detail. The closed suction technique requires inpatient admission and is not a procedure to be performed in the Emergency Department. It will therefore not be described here.

Aspiration

Some consider the aspiration technique to be the primary method to evacuate an auricular hematoma.2,3,5,6 They reserve the incision and drainage technique for incomplete aspiration or recurrence of the hematoma. Unfortunately, the hematoma frequently recurs after using the aspiration technique and the patient requires a second procedure to evacuate the hematoma.1,3,6,19 Because of the high rate of recurrence, this author and others prefer to use the incision and drainage technique as the primary procedure.16

Clean and prep the skin. Anesthesia is achieved by performing a regional auricular block or by placing a skin wheal of local anesthetic over the hematoma. Attach an 18 gauge needle onto a 10 mL syringe. Insert the needle into the area of maximum fluctuance (Figure 168-6). Apply negative pressure to the syringe, by withdrawing the plunger, to evacuate the hematoma. Express or “milk” the hematoma between the thumb and index finger of the nondominant hand while applying negative pressure with the syringe to ensure complete evacuation of the hematoma (Figure 168-6).

Remove the needle and apply manual pressure to the area of the former hematoma for 3 to 5 minutes. If the hematoma recurs or if complete aspiration is not possible, perform the incision and drainage technique. If the hematoma is completely evacuated and does not recur, apply topical antibiotic ointment and a pressure dressing.

There are several disadvantages to this technique. First, the hematoma frequently recurs.1,3,6,19 This means that the patient often needs a second drainage procedure. Even if the hematoma is adequately evacuated, the elimination of the dead space is problematic.19 The dead space may fill with blood or serous fluid requiring a second procedure. A surgically applied pressure dressing may alleviate the dead space and make the aspiration technique more successful. Finally, the aspiration technique may not remove all of the hematoma.1 Again, the patient will need a second procedure. For these above stated reasons, the aspiration technique is not the preferred method to drain an auricular hematoma.

Incision and Drainage

This is the preferred technique to evacuate an auricular hematoma.16 It requires a regional auricular block for anesthesia. This technique takes more time to perform than the aspiration technique.

As noted previously, the skin should be cleaned and prepped in the usual manner. Perform a regional auricular block to provide adequate analgesia. Allow the block 10 to 15 minutes to achieve maximal effect.17 Incise the auricular skin with a #15 surgical scalpel blade at the edge of the hematoma (Figure 168-7A). When making the incision, it should follow the curvature of the pinna and be no longer than 1 cm. Gently peel this skin and attached perichondrium off the hematoma using forceps. Express or “milk” the hematoma with the thumb and index finger of the nondominant hand. Insert a curved hemostat and gently loosen any remaining blood clot (Figure 168-7B). Fill a 10 mL syringe with sterile saline and attach a plastic 18 gauge angiocatheter. Gently flush out the area of the hematoma (Figure 168-7C).

Reapproximate the skin and perichondrium on the cartilage. Compress the tissue to eliminate any fluid and dead space. Some authors apply a small rubber drain through the incision to prevent accumulation of blood or serous fluid.4,8 The use of a drain is optional. A drain can be made by cutting a small strip from a sterile Penrose drain.

Apply manual pressure to the area of the former hematoma for 3 to 5 minutes. If the hematoma or serous fluid does not reaccumulate, apply topical antibiotic ointment and a pressure dressing as described below. If the hematoma or serous fluid does reaccumulate, consider inserting a rubber drain or applying a surgical pressure dressing.

A pressure dressing must be applied to the auricle after the successful drainage of an auricular hematoma. It prevents reaccumulation of the hematoma or serous fluid, and supports the auricle while the perichondrium reattaches to the cartilage.3,6,10 The pressure dressing must be applied for at least 48 hours.4 The pressure dressing can be the traditional mastoid dressing or a surgically applied dressing.16,17,19,20 These pressure dressings apply even pressure over the entire auricle without compromising the blood flow while simultaneously eliminating the dead space within the wound.17

Mastoid Pressure Dressing

The most commonly applied dressing is the mastoid pressure dressing (Figure 168-8). Although simple to place, it has many disadvantages when compared to the surgically applied pressure dressing. It is bulky and hard to keep in place. It is very conspicuous. Patients must keep it dry and remain relatively inactive to prevent it from coming off.

Place a piece of sterile dry cotton in the external auditory canal and level with the base of the auricular cartilage. Mold a sterile material that conforms easily onto all the convolutions of the auricle until it is level with the lateral helical rim (Figure 168-8A). The choices of material include cotton balls soaked in mineral oil, cotton balls soaked in saline, or petrolatum gauze. The material chosen is left to Emergency Physician preference and what is available in the Emergency Department. This author prefers to use petrolatum gauze. The petrolatum gauze allows the dressing to be removed with minimal trauma to the ear. Pack the auricle with saline-soaked cotton balls. All the convolutions of the auricle must be thoroughly packed. The packing of the auricular convolutions assures even application of pressure to all portions of the auricle.

Cut out and discard a semicircle or a V-shaped section from a pile of gauze squares. Place the remaining C-shaped gauze pads behind the auricle (Figure 168-8B). The gauze pads should be built up until they completely fill the area between the auricle and the head. This padding is used to support the auricle as well as prevent undue contortion or uneven pressure from the compression dressing.2

Unfold and fluff several gauze squares or open a roll of gauze. Place the fluffed gauze over the lateral surface of the auricle (Figure 168-8C). Wrap an elastic bandage snugly over the auricle and around the head to hold the dressing in place (Figure 168-8D). The circumferential head dressing should not encompass the opposite auricle. The elastic bandage is used to compress the auricle between the two layers of gauze padding.

Surgical Pressure Dressing

A surgically applied pressure dressing may be used instead of the traditional mastoid dressing (Figure 168-9).1,7,16,19 This dressing applies even pressure over the former hematoma site to prevent reaccumulation. It takes more skill to apply than the traditional mastoid dressing. Aseptic technique is mandatory to prevent infection and perichondritis. This dressing requires a skin prep of a much wider area to include the entire medial and lateral surface of the ear, and the surrounding skin.

The surgically applied pressure dressing has many advantages over the traditional mastoid dressing. It produces pressure exactly where it is needed. The wound is not obscured with a bulky dressing. This allows the patient to easily observe and monitor the site for reaccumulation of fluid and possible infection. This dressing is comfortable and well tolerated by the patient. It is unlike the bulky and conspicuous mastoid dressing that is difficult to keep in place, especially when sleeping. The dressing can remain in place while monitoring the auricle, unlike the mastoid dressing that must be removed and replaced daily. The patient can remain active, including taking a shower, without fear of the dressing coming undone. The surgical pressure dressing is adaptable to any location or a variety of hematomas.

Trim a cotton dental bolster or cotton roll to fit the convolution of the auricle over the site of the drained hematoma. Place the cotton roll over the site of the former hematoma (Figure 168-9A). Place a second dental roll on the medial surface of the auricle opposite the first dental roll (Figures 168-9A & B). Place the needle of a 4-0 monofilament nylon suture immediately adjacent to the first cotton bolster. Pass the suture through the entire thickness of the auricle and out the medial surface. Pass the needle over the second cotton bolster and back through the auricle. Snugly tie the suture over the anterior cotton bolster (Figure 168-9B). The suture should be snug enough to allow the cotton bolsters to firmly hold the perichondrium to the cartilage without causing vascular compromise. Apply additional sutures using the same technique until the cotton bolsters are firmly attached and any dead space is eliminated. Depending upon the location of the hematoma, it may require a minimum of two to a maximum of four bolsters to reapproximate the skin and perichondrium and to eliminate all of the dead space.

Monofilament nylon is the preferred suture material for this procedure.7 It causes less tissue reaction than silk, cotton, gut, or absorbable sutures. It has less of a tendency to cut the ear tissues when tied over the cotton bolsters. Monofilament nylon is less likely to wick bacteria into the auricle and cause an infection than multifilament nylon. The suture may be safely left in place for up to 3 weeks without any complications.

Alternative Techniques

An alternative to packing the pinna with petrolatum gauze is to use either ENT silicone putty or dental impression material.22,25 Evacuate the hematoma as described previously. Mix the chosen material to form a uniform composite and activate it. Mold it to fill the pinna, wrapping over the pinna and filling the space between the medial surface of the ear and the head. The putty or impression material will solidify in a few minutes after mixing it and the application. Apply an elastic bandage as described previously. Unfortunately, ENT silicone putty and dental impression material is not often available in the Emergency Department.

The placement of cotton bolsters is often cumbersome and difficult if the Emergency Physician has little experience with this technique. An alternative is to use thermoplastic splinting material.24 Trim a sheet of thermoplastic splinting material to form a lateral and medial splint of an appropriate size to conform to the lateral and medial surfaces of the ear, respectively. Place the splints in warm water to soften them. Apply the splints to the surfaces of the ear, mold them to the contours of the ear, and apply pressure until they cool and become rigid again. Suture the rigid splints through the ear as described previously.

A second surgical alternative to the use of bolsters is to apply running mattress sutures through the ear to reapproximate the skin and perichondrium.26–28 Begin posteriorly and weave 4-0 Vicryl or chromic gut suture through-and-through the ear in a running pattern to reapproximate the soft tissues and repair the ear contours. The main advantages of this technique include eliminating bolsters, eliminating the bulky dressing, and the comparable success rates while minimizing the reaccumulation of blood or fluid.

The postprocedural care of the auricle is as important as the initial hematoma evacuation. Proper follow-up and care can minimize or prevent any cosmetic deformities. All patients should be seen within 12 to 24 hours to reevaluate the auricle for infection or reaccumulation of the hematoma or serous fluid. Analgesia can be provided by the use of nonsteroidal anti-inflammatory agents. Determine the patient's tetanus immune status and provide prophylaxis as required.

Provide all patients with oral and written instructions regarding the signs and symptoms of cellulitis and perichondritis. This includes the immediate return to the Emergency Department for increasing pain, progressive swelling, redness, tenderness, and warmth. Prophylaxis with oral antibiotics is indicated with any laceration, incision, or puncture of the auricular skin.4 Prescribe antibiotics for 5 days.4,5,16 Recommendations include a range of first-generation cephalosporins, antistaphylococcal antibiotics, or antipseudomonal antibiotics.4,5,16

Apply the pressure dressing for a minimum of 48 hours.4 A pressure dressing is recommended for a total of 4 to 5 days. A mastoid dressing must be removed daily to evaluate the auricle, then reapplied. A surgically applied dressing will avoid daily visits to the physician.

Drain any residual clot or serous fluid at the follow-up visit. This can easily be accomplished by needle aspiration and replacement of the pressure dressing.6,20 If necessary, a sterile drain can be inserted.8 All drains must be removed within 48 hours of placement to decrease the risk of infection.

The complications are primarily related to incomplete evacuation of the hematoma or reaccumulation of the hematoma. Incomplete evacuation of the hematoma, if by the aspiration technique, requires an incision and drainage of the hematoma. If necessary, gentle curettage of the cartilage with a hemostat should dislodge the clot. Reaccumulation of the hematoma, or serous fluid, must be evacuated. Consider placing a sterile drain into the incision.8 Another option is to place a surgical pressure dressing.7 A hematoma located within the cartilage will result in a treatment failure and require operative management.29

Infection may complicate any surgical procedure. This may be due to reaccumulation or incomplete evacuation of the hematoma, which then becomes infected. Strict adherence to aseptic technique will usually prevent infection. Since patients are prophylactically placed on antibiotics, any cellulitis of the auricle at the follow-up visits requires hospital admission and intravenous antibiotics.

Perichondritis is the most feared complication. It is an aggressive and rapidly progressive infection. The auricle will become red, hot, and exquisitely tender if perichondritis develops. This is followed by diffuse swelling and abscess formation. This infection can lead to significant cartilage necrosis and a deformed ear if not promptly treated. Pseudomonas aeruginosa is isolated in 95% of patients with perichondritis.1 Over 50% of cases are polymicrobial with Staphylococcus aureus associated with P. aeruginosa. These patients require Otolaryngology or Plastic Surgery consults for surgical debridement, broad spectrum intravenous antibiotics, and hospital admission.1,8

An auricular hematoma forms in minutes to hours after blunt trauma to the ear. It presents as a firm and painful swelling that obscures the normal convolutions on the lateral aspect of the auricle. It requires drainage to restore the normal convolutions of the auricle and prevent future deformity. Complete evacuation can be accomplished by needle aspiration or by incision and drainage. After the procedure, prescribe oral antibiotics prophylactically to prevent infection. Follow-up is required within 12 to 24 hours of the procedure to evaluate the patient for reaccumulation of the hematoma and infection. Patients should be educated about the signs and symptoms of perichondritis. Frequent wound evaluation is required until the auricle is healed.