The Laryngoscope

Lippincott Williams & Wilkins, Inc.

© 2005 The American Laryngological,
Rhinological and Otological Society, Inc.

Rethinking Auricular Trauma

Tamer Ghanem, MD, PhD; J. K. Rasamny, BA; Stephen S. Park, MD

Objectives/Hypothesis: An unrecognized auricu- INTRODUCTION

lar hematoma can lead to a disfiguring deformity, the An auricular hematoma occurs because of blunt
cauliflower ear, but it can be prevented with prompt trauma to the auricle.1,2 Unrecognized or improperly
and comprehensive management. Fine needle aspira- treated, it can result in the conspicuous cauliflower ear
tion with pressure bandages remains the mainstay deformity, which has been recognized since the ancient
treatment but will occasionally fail. We review our Greek wrestlers. In fact, the deformity remains a common
experience with recurrent or recalcitrant auricular stigmata to wrestlers, boxers, and rugby players. The un-
hematomas in terms of their pathophysiology and re-
managed auricular hematoma can lead to infection, carti-
vision surgery. Study Design: Retrospective chart re-
lage necrosis, contracture, and neocartilage formation.
view. Methods: A review of patients undergoing sur-
gical incision, drainage, and debridement secondary There are a variety of treatments aimed at preventing
to recurrent auricular hematomas was conducted. these complications and returning the auricle to its pre-
Demographic data was collected, intraoperative trauma form.3–11 Typically, a graduated approach is un-
notes were reviewed, and follow-up results were ob- dertaken depending on the extent of the injury and the
tained. Our management included an open incision, time from initial insult. For small hematomas that are
aggressive debridement, and long term bolsters to the discovered acutely, a needle aspiration with a bolster
ear. Results: Ten patients presented with a persistent dressing is recommended. For a few days postinjury, the
auricular hematoma and deformity following outpa- hematoma will become a coagulated clot, and needle aspi-
tient management with either incision and drainage ration is often ineffective. After roughly a week, the clot
or fine needle aspiration. All were male with a mean usually breaks down, and aspiration is once again possi-
age of 25 years, presenting for surgery on average 19 ble. Larger hematomas may warrant an open approach or
days following initial trauma. The location of the he- placement of a drain. Postoperative antibiotic prophylaxis
matoma within this group was not limited to the po- against skin flora is generally recommended. Despite
tential space between the cartilage and perichon- these measures, treatment of auricular hematomas can be
drium. The hematoma was clearly located within the
frustrating because of their common recurrence, which
cartilage itself and it is postulated that this is one of
can occur several days postevacuation.
the primary reasons for initial failure. Following sur-
gical incision and drainage there were no recur- Complete extirpation of auricular hematomas is
rences or complications. Conclusion: There is a select therefore key to adequate treatment. To completely evac-
group of patients with refractory auricular hemato- uate the auricular hematoma, it is important for the sur-
mas that require more aggressive treatment over a geon to have a proper understanding of the pathophysiol-
fine needle aspiration. Open debridement is indicated ogy of auricular hematoma. Blunt trauma causes shearing
for this group. The location of the hematoma, granu- forces between the anterior auricular skin, perichon-
lation tissue, and neo-cartilage is found to be within drium, and cartilage. Classically, the hematoma is
the cartilage itself rather than between the cartilage thought to form in the potential space between the peri-
and perichondrium, thus explaining why a needle as- chondrium and ear cartilage.1 Careful studies investigat-
piration alone can be ineffective. Key Words: Auricu- ing the etiology of this deformity suggest that the hema-
lar trauma, auricular hematoma, surgical manage- toma actually occurs intracartilaginously (i.e., in the ear
ment, cauliflower ear. cartilage itself).2 The basis for these studies will be ex-
Laryngoscope, 115:1251–1255, 2005 plored further in the Discussion section. Once the hema-
toma forms, it will organize with fibroblast infiltration
and eventual neocartilage formation. One reason for re-
From the Department of Otolaryngology—Head and Neck Surgery, currence or for progression to the cauliflower deformity is
University of Virginia, Charlottesville, Virginia, U.S.A.
incomplete removal of the hematoma, which is expected to
Editor’s Note: This Manuscript was accepted for publication March
15, 2005. occur with multiloculated hematomas arising within the
Send Correspondence to Dr. Stephen S. Park, Department of Oto- cartilage proper.
laryngology—Head and Neck Surgery, PO Box 800713, University of Vir- The purpose of this paper is to review our experience
ginia, Charlottesville, VA 22908, U.S.A.
with the management of recurrent auricular hematomas
DOI: 10.1097/01.MLG.0000165377.92622.EF and to explore their pathophysiology. The study subjects

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1251
were limited to patients with recurrent or persistent he- The other four hematomas were firm to palpation and
matomas of the ear. were not felt to be amenable to needle aspiration. Those
patients went directly to surgical incision and drainage,
MATERIALS AND METHODS without attempts at needle aspiration. Hematomas oc-
A retrospective chart review was conducted for patients curred along the superior half of the ear, involving the
with auricular hematomas treated at a tertiary care hospital scaphoid fossa, triangular fossa, antihelix, concha cymba,
between December 2001 and May 2004. Prior approval was ob-
and concha cavum. The location of the hematoma was
tained from the human investigation committee. All patients
determined through the operative note and found to be
included in this study underwent surgical incision and drainage
of their auricular hematoma. Demographic data, previous proce- intracartilagenous (i.e., sheets of native cartilage could be
dures, intraoperative findings, follow-up results, and complica- found on both the anterior and posterior borders of the
tions were recorded. hematoma). The lesions consisted of clot, serum, fibrous
An anterior incision was made along the inner aspect of the tissue, and fragments of normal cartilage. There were no
helix or antihelix, depending on the epicenter of the hematoma. A complications or recurrences on follow-up of at least 1
skin flap was elevated over the underlying hematoma with care month. All patients were specifically instructed to return
taken to identify the precise location of the lesion with respect to if there were any signs of erythema, tenderness, or recur-
the perichondrium and cartilage. All blood, granulation tissue,
rent swelling.
necrotic cartilage, and fibrous tissues were completely evacuated.
The skin was closed with absorbing suture and a through-and-
through bolster dressing applied for 1 week. Perioperative sys-
temic antibiotics were prescribed for 7 days. Case Presentation
A sixteen-year-old male wrestler presented 2 weeks
RESULTS after suffering a right auricular hematoma in a wrestling
Ten patients with recurrent auricular hematomas match. He had two previous unsuccessful fine needle as-
were identified from February 2001 to March 2004 and piration procedures with a dental roll bolster dressing by
included in this study. All were male with a mean age of an outside otolaryngologist. His preoperative photographs
25 (14 – 49) years. Causation in descending frequency were are shown in Figure 1. He was taken to the operating room
wrestling (n ⫽ 4), fighting (n ⫽ 3), self-inflicted (n ⫽ 1), on posttrauma day 22 for incision and drainage. The inci-
and unknown (n ⫽ 2). The time interval from trauma to sion was made along the inside surface of the helix, and
the surgical intervention ranged from 2 to 38 (mean 19) the skin was elevated off the lesion (Fig. 2). The hema-
days. Five patients underwent previous unsuccessful nee- toma was located within the cartilage, as shown in Figure
dle aspirations: three patients underwent one previous 3. The hematoma and excess cartilage were debrided, the
unsuccessful needle aspiration, and two patients had two wound irrigated and closed, and a transauricular pressure
previous unsuccessful needle aspirations. One patient had bandage applied (Fig. 4). On 10-month follow-up, he had
two unsuccessful attempts at open incision and drainage. no evidence of hematoma recurrence (Fig. 5).

Fig. 1. (A) Side view of 16 year old

patient with a 2-week-old auricular
hematoma. (B) Front view.

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1252
Fig. 2. (A) Incision site along the
inner aspect of the helix. (B) View
after elevation of the anterior auricu-
lar skin, showing deformed ear carti-
lage.

DISCUSSION studying auricular hematoma pathophysiology than in-

There is controversy in the literature as to the precise jecting blood clots in rabbit ears.
location of the traumatic auricular hematoma, but classic The current study addresses recurrent hematomas
teaching is that they occur between the perichondrium and does not reflect the typical patient with blunt auric-
and cartilage. This dogma is derived from a study by ular trauma; a majority are probably successfully man-
Ohlsen et al.1 in which they surgically injected blood clots aged with needle aspiration and short-term bolsters. Even
in different locations in the rabbit ear. When the blood clot larger fluctuant hematomas can be aspirated. The location
was placed between the skin and perichondrium, the blood of these common hematomas may indeed be between the
clot resorbed in 21 days. However, if the blood clot was cartilage and perichondrium. Within our recurrent/persis-
placed between the perichondrium and cartilage, new car- tent patient group, however, the location of the auricular
tilage formed within the subperichondrial plane over a hematoma was clearly described and discovered to be
4-week interval. The possibility of a hematoma originally within the cartilage proper. Operative dissection not only
forming within the ear cartilage itself was not specifically confirmed this location but also the presence of fibrous
tested in this study. This study is widely cited and is the tissue and neocartilage. This multiloculated geometry
basis for our current understanding of the pathophysiol- would predispose to failure after a single puncture and
ogy of auricular hematomas. aspiration. For this subgroup of patients, an aggressive
Two years before the above study, another experi- extirpation of the hematoma with debridement is required
ment was performed to address the same question. A to prevent recurrence. The current results are similar to
rabbit animal model was used to simulate auricular those reported elsewhere; however, the exact location
hematomas by dropping a 10 g weight from a fixed within the cartilage was not discussed.4,6,11 An aggressive
height on the lateral aspect of the pinna.2 The cartilage extirpation was the treatment of choice.
was evaluated at various time points by histologic sec- Long-term follow-up can be a challenge because
tioning and light microscopy. Hematoma formation was many patients were referred by otolaryngologists from a
more likely if the force was tangential, producing a distance. Each patient was specifically instructed to call or
shearing force between skin and cartilage. The hemato- return for any signs of recurrence, and none did. Hema-
mas were mostly found to be intracartilaginous and tomas would certainly recur within a month but the fibro-
associated with a tear through the cartilage. The hema- sis and contracture could be a later sequelae and more
toma was replaced by fibrous tissue, with the fibroblast difficult to tract. The patient in the case presentation was
slowly producing immature neocartilage. The combina- followed for 10 months, and he was free of recurrence and
tion of fibrosis, contracture, and neocartilage was contracture.
thought to be the pathogenesis of the cauliflower ear Auricular hematomas can be divided in two catego-
deformity seen clinically. This study, although less cited ries to help in therapy. Fluctuant hematomas that are
in the literature, takes a more physiologic approach to discovered acutely can usually be managed with needle

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1253
 Fig. 3. (A) The deformed ear cartilage
is opened and fibrous tissue and he-
matoma is seen. (B) The fibrous tis-
sue and hematoma is extirpated, ex-
cess native ear cartilage is held
between the forceps, demonstrating
the location of the hematoma.

aspiration. The second group represents those older he- CONCLUSIONS

matomas that tend to be more fibrotic in nature or those Auricular hematomas arise from blunt trauma to the
that are recurrent after needle aspiration, which often auricle. Shearing forces between the anterior auricular
require an open evacuation. Hematomas located within skin and underlying cartilage are believed to be responsi-
the cartilage itself may be predisposed to recurrence and ble for the hematoma. The location of the hematoma has
warrant the more aggressive initial treatment. been classically described as between the perichondrium
and cartilage; however, in some patient groups, the hema-
tomas can arise within the cartilage itself. These findings
are clinically useful as guidelines in the management of
auricular hematomas. First, complete evacuation of the
hematoma and fibrous tissue needs to be performed
through adequate access. All abnormal neocartilage and
fibrous tissues should be aggressively debrided.

Fig. 5. Ten-month follow-up side views: (A) right ear post incision
Fig. 4. Immediate postoperative period. and drainage, and (B) left ear.

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