18-05: Ear Lacerations

Clinical Summary

The ear is composed of a poorly vascularized cartilaginous skeleton covered by tightly adherent skin. Given the paucity of subcutaneous tissue, injury that results in hematoma formation can cause cartilage pressure necrosis. Repair involves completely covering the exposed cartilage and preventing hematoma formation.

Management and Disposition

Prior to repair, the area is examined for signs of acute hematoma formation or other associated traumatic injuries. Hemotympanum or Battle sign suggests the presence of a more serious closed head injury, especially basilar skull fracture. Blunt trauma may result in barotrauma resulting in tympanic membrane perforation. Exam can be facilitated by local anesthesia infiltration or, in the case of larger or more complex lacerations, a regional nerve block.

Simple lacerations through the earlobe or the helix can be repaired with interrupted 6-0 nonabsorbable monofilament sutures if the cartilage is not exposed. Simple lacerations that involve the cartilage are primarily repaired by ensuring complete coverage of the exposed cartilage by careful apposition of the overlying skin. The skin generally provides enough support, so sutures are not required for the cartilage itself. If the wound is sufficiently irregular and cartilage debridement becomes necessary to avoid undue wound tension, the debridement should be kept to a minimum.

A perichondral hematoma must be drained within 72 hours to prevent potential pressure necrosis, which can result in a “cauliflower” ear. Ear wounds are best dressed with a mastoid pressure dressing either primarily or after later hematoma drainage. Such a dressing reduces the chances for future hematoma formation and its complications. Ear sutures are removed in 4 to 5 days.

Pearls

1. Hematoma evacuation needs to be rechecked in 24 hours to evaluate for reaccumulation.

2. If cartilage has been exposed or a hematoma drained, antistaphylococcal antibiotic coverage is recommended.

3. Complex lacerations and hematomas of the ear are best cared for in conjunction with a consultant from otorhinolaryngology (ENT) or plastic surgery.